Provider Demographics
NPI:1851657837
Name:WAGNER - SEARS, EVONNE (SOTP)
Entity Type:Individual
Prefix:MS
First Name:EVONNE
Middle Name:
Last Name:WAGNER - SEARS
Suffix:
Gender:F
Credentials:SOTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16301 NE 8TH ST STE 251
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98008-3992
Mailing Address - Country:US
Mailing Address - Phone:206-595-2779
Mailing Address - Fax:
Practice Address - Street 1:16301 NE 8TH ST STE 251
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008-3992
Practice Address - Country:US
Practice Address - Phone:206-595-2779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAF60133217101YM0800X
WAHP60154364101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health