Provider Demographics
NPI:1588011993
Name:EVANS, OPAL (LGP)
Entity Type:Individual
Prefix:
First Name:OPAL
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LGP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 DEEP LANDING RD
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20639-9586
Mailing Address - Country:US
Mailing Address - Phone:573-239-0554
Mailing Address - Fax:
Practice Address - Street 1:65 DUKE ST
Practice Address - Street 2:STE 202
Practice Address - City:PRINCE FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:20678-6128
Practice Address - Country:US
Practice Address - Phone:573-239-0554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP6812101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor