Provider Demographics
NPI:1407141476
Name:EDWARDS, EVONNE M (LLP)
Entity Type:Individual
Prefix:
First Name:EVONNE
Middle Name:M
Last Name:EDWARDS
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:EVONNE
Other - Middle Name:M
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLP
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:
Practice Address - Street 1:4211 PARKWAY PL SW
Practice Address - Street 2:
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418-2695
Practice Address - Country:US
Practice Address - Phone:616-222-3700
Practice Address - Fax:616-222-3707
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014805103T00000X
MI6301015324103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist