Provider Demographics
NPI:1649756479
Name:EVANS, EMMA OLSON
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:OLSON
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 BOUCHER AVE
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21403-2407
Mailing Address - Country:US
Mailing Address - Phone:630-335-7523
Mailing Address - Fax:
Practice Address - Street 1:805 BOUCHER AVE
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21403-2407
Practice Address - Country:US
Practice Address - Phone:630-335-7523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-16
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician