Provider Demographics
NPI:1639364706
Name:EVANS, PATRICE MAREE (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:PATRICE
Middle Name:MAREE
Last Name:EVANS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 435
Mailing Address - Street 2:
Mailing Address - City:MUNISING
Mailing Address - State:MI
Mailing Address - Zip Code:49862-0435
Mailing Address - Country:US
Mailing Address - Phone:906-387-6404
Mailing Address - Fax:888-405-0628
Practice Address - Street 1:202 ELM AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:MUNISING
Practice Address - State:MI
Practice Address - Zip Code:49862-1108
Practice Address - Country:US
Practice Address - Phone:906-387-6404
Practice Address - Fax:888-405-0628
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010854551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI5062OtherMEDICARE PTAN