Provider Demographics
NPI:1336120104
Name:EVANS, DIANA GRACE (LBSW)
Entity Type:Individual
Prefix:MS
First Name:DIANA
Middle Name:GRACE
Last Name:EVANS
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:MS
Other - First Name:DIANA
Other - Middle Name:GRACE
Other - Last Name:RANK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LBSW
Mailing Address - Street 1:677A EAST MAIN
Mailing Address - Street 2:
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032
Mailing Address - Country:US
Mailing Address - Phone:269-467-1000
Mailing Address - Fax:269-467-3075
Practice Address - Street 1:677A EAST MAIN
Practice Address - Street 2:
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032
Practice Address - Country:US
Practice Address - Phone:269-467-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2009-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68020812461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1708146Medicaid
MI1708146Medicaid