Provider Demographics
NPI:1881686210
Name:EVANS, CHARLES EDWARD (CADC CPADAC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDWARD
Last Name:EVANS
Suffix:
Gender:M
Credentials:CADC CPADAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5606 FORT ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-1740
Mailing Address - Country:US
Mailing Address - Phone:402-455-8325
Mailing Address - Fax:402-455-4682
Practice Address - Street 1:515 E BROADWAY
Practice Address - Street 2:
Practice Address - City:COUNCIL BLUFFS
Practice Address - State:IA
Practice Address - Zip Code:51503-4419
Practice Address - Country:US
Practice Address - Phone:712-322-1407
Practice Address - Fax:712-322-6833
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG01096626101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)