Provider Demographics
NPI:1922320100
Name:EVANS, MICHELLE (LCPC, LPC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LCPC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1603
Mailing Address - Street 2:
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-1603
Mailing Address - Country:US
Mailing Address - Phone:301-535-4603
Mailing Address - Fax:
Practice Address - Street 1:109 LA GRANGE AVE
Practice Address - Street 2:SUITE 103
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-9592
Practice Address - Country:US
Practice Address - Phone:301-535-4603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-16
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC2364101YP2500X
DCPRC13950101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD80-0537466OtherINTERNAL REVENUE SERVICE