Provider Demographics
NPI:1790331858
Name:EVANS, ELISSA CAE (LCSW)
Entity Type:Individual
Prefix:
First Name:ELISSA
Middle Name:CAE
Last Name:EVANS
Suffix:
Gender:F
Credentials:LCSW
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 784
Mailing Address - Street 2:
Mailing Address - City:PANACA
Mailing Address - State:NV
Mailing Address - Zip Code:89042-0784
Mailing Address - Country:US
Mailing Address - Phone:702-461-6484
Mailing Address - Fax:
Practice Address - Street 1:88 E FIDDLERS CANYON RD STE 122
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-9787
Practice Address - Country:US
Practice Address - Phone:702-775-2738
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1041C0700X
UT1041C0700X
NV00722P101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical