Provider Demographics
NPI:1477018513
Name:EVANS, DUSTIN (LLMSW)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:LLMSW
Other - Prefix:
Other - First Name:APRIL
Other - Middle Name:
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LLMSW
Mailing Address - Street 1:2193 EASTCASTLE DR SE UNIT 104
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-7751
Mailing Address - Country:US
Mailing Address - Phone:434-328-9325
Mailing Address - Fax:
Practice Address - Street 1:4829 E BELTLINE AVE NE STE 101
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9349
Practice Address - Country:US
Practice Address - Phone:616-303-1833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-03
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI68511146091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician