Provider Demographics
NPI:1912004581
Name:EVANS, ANNETTE RENEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ANNETTE
Middle Name:RENEE
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 1:1042 N MILFORD RD STE 203
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-5109
Mailing Address - Country:US
Mailing Address - Phone:248-684-6003
Mailing Address - Fax:248-684-6007
Practice Address - Street 1:1042 N MILFORD RD STE 203
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-5109
Practice Address - Country:US
Practice Address - Phone:248-684-6003
Practice Address - Fax:248-684-6007
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012090103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI680F328270OtherBC/BS PIN
MI2981001Medicare PIN
MI12981Medicare UPIN
MIP22560001Medicare ID - Type Unspecified