Provider Demographics
NPI:1922799048
Name:EVANS, NICHOLAS (LSW)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 N 7TH AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5788
Mailing Address - Country:US
Mailing Address - Phone:208-515-1668
Mailing Address - Fax:
Practice Address - Street 1:1001 N 7TH AVE STE 260
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5788
Practice Address - Country:US
Practice Address - Phone:208-515-1668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLSW-42210101Y00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor