Provider Demographics
NPI:1437452406
Name:PARKS, EVAN DANIEL (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:DANIEL
Last Name:PARKS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 WEALTHY ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5247
Mailing Address - Country:US
Mailing Address - Phone:616-840-8000
Mailing Address - Fax:616-840-8224
Practice Address - Street 1:350 LAFAYETTE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4656
Practice Address - Country:US
Practice Address - Phone:616-840-8402
Practice Address - Fax:616-840-9771
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-14
Last Update Date:2023-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006916103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1437452406Medicaid