Provider Demographics
NPI:1851433700
Name:EVANS, MARY BETH (LCSW)
Entity Type:Individual
Prefix:
First Name:MARY BETH
Middle Name:
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 1:4355 SPRING GLEN DR
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:AR
Mailing Address - Zip Code:72120-5112
Mailing Address - Country:US
Mailing Address - Phone:501-650-4925
Mailing Address - Fax:
Practice Address - Street 1:114 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-4625
Practice Address - Country:US
Practice Address - Phone:501-834-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2245-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149004401Other101Y00000X