Provider Demographics
NPI:1598000374
Name:EVJEN, HEATHER (MA,LLP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:EVJEN
Suffix:
Gender:F
Credentials:MA,LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2252 ELLERY AVE
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48327-1106
Mailing Address - Country:US
Mailing Address - Phone:248-613-0546
Mailing Address - Fax:
Practice Address - Street 1:2011 CROOKS RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-4049
Practice Address - Country:US
Practice Address - Phone:248-613-0546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012077103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical