Provider Demographics
NPI:1477984599
Name:EVANS, SHANNON
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 SALVATORE CT
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-2436
Mailing Address - Country:US
Mailing Address - Phone:201-838-0153
Mailing Address - Fax:
Practice Address - Street 1:78 SALVATORE CT
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-2436
Practice Address - Country:US
Practice Address - Phone:201-838-0153
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-30
Last Update Date:2013-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical