Provider Demographics
NPI:1558769976
Name:EVANS, LANDON WALKER (MA)
Entity Type:Individual
Prefix:MR
First Name:LANDON
Middle Name:WALKER
Last Name:EVANS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BONNIEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MINERVA
Mailing Address - State:OH
Mailing Address - Zip Code:44657-2014
Mailing Address - Country:US
Mailing Address - Phone:330-205-0596
Mailing Address - Fax:
Practice Address - Street 1:130 BONNIEVIEW AVE
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657-2014
Practice Address - Country:US
Practice Address - Phone:330-205-0596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH3206459103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool