Provider Demographics
NPI:1538487541
Name:EVANS-GEAN, AMY MICHELLE (LPC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:MICHELLE
Last Name:EVANS-GEAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:MICHELLE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:304 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:BULLARD
Mailing Address - State:TX
Mailing Address - Zip Code:75757-5024
Mailing Address - Country:US
Mailing Address - Phone:903-521-0268
Mailing Address - Fax:
Practice Address - Street 1:4713 TROUP HWY
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-2354
Practice Address - Country:US
Practice Address - Phone:903-581-7542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-14
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64157101YM0800X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional