Provider Demographics
NPI:1467515817
Name:EVANS, TERESE W (LPC)
Entity Type:Individual
Prefix:MS
First Name:TERESE
Middle Name:W
Last Name:EVANS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2440 POCAHONTAS PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63144-2104
Mailing Address - Country:US
Mailing Address - Phone:503-679-8819
Mailing Address - Fax:636-561-0463
Practice Address - Street 1:7400 HIGHWAY N
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-7013
Practice Address - Country:US
Practice Address - Phone:636-561-7080
Practice Address - Fax:636-561-0463
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003023374101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO178679OtherBLUE CROSS BLUS SHIELD