Provider Demographics
NPI:1023177201
Name:EVANS, BARRY LEROY (MASTER SOCIAL WORK)
Entity type:Individual
Prefix:MR
First Name:BARRY
Middle Name:LEROY
Last Name:EVANS
Suffix:
Gender:M
Credentials:MASTER SOCIAL WORK
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5285 COUNTY ROAD 4 NE
Mailing Address - Street 2:
Mailing Address - City:ATWATER
Mailing Address - State:MN
Mailing Address - Zip Code:56209
Mailing Address - Country:US
Mailing Address - Phone:320-235-4613
Mailing Address - Fax:320-231-9140
Practice Address - Street 1:1125 6TH STREET SE
Practice Address - Street 2:WOODLAND CENTERS
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-4675
Practice Address - Country:US
Practice Address - Phone:320-231-9148
Practice Address - Fax:320-231-9140
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1013109OtherPREFERRED ONE
115671OtherUCARE
30024EVOtherBLUE CROSS
6220225OtherUBH