Provider Demographics
NPI:1255789632
Name:EVANS, MARY K (LPC, MA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:EVANS
Suffix:
Gender:F
Credentials:LPC, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 W OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-2716
Mailing Address - Country:US
Mailing Address - Phone:970-310-3406
Mailing Address - Fax:
Practice Address - Street 1:320 W OLIVE ST
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521
Practice Address - Country:US
Practice Address - Phone:970-310-3406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-26
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0015327101YP2500X
IL180.004735101YP2500X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional