Provider Demographics
NPI:1881690063
Name:EVANS, SUSAN M (PHD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:M
Last Name:EVANS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12634 ANGLING RD
Mailing Address - Street 2:
Mailing Address - City:EDINBORO
Mailing Address - State:PA
Mailing Address - Zip Code:16412-1369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12634 ANGLING RD
Practice Address - Street 2:
Practice Address - City:EDINBORO
Practice Address - State:PA
Practice Address - Zip Code:16412-1369
Practice Address - Country:US
Practice Address - Phone:814-449-7542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS-005771-L103G00000X
PAPS005771L103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1013543460003Medicaid
PA1013543460004Medicaid
PA1013543460005Medicaid
PA1013543460004Medicaid