Provider Demographics
NPI:1811040652
Name:EVANSON, MANDI E (LCSW)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:E
Last Name:EVANSON
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 1:305 N OAK PARK AVE
Mailing Address - Street 2:1B
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2157
Mailing Address - Country:US
Mailing Address - Phone:248-420-3235
Mailing Address - Fax:
Practice Address - Street 1:4700 W 95TH ST
Practice Address - Street 2:SUITE 104
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2533
Practice Address - Country:US
Practice Address - Phone:708-202-9922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.010889104100000X
IL1490133201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker