Provider Demographics
NPI:1396808739
Name:EVANS, GLENN WILLIAM (MA, LLPC)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:WILLIAM
Last Name:EVANS
Suffix:
Gender:M
Credentials:MA, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 VICTOR DR
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48609-5184
Mailing Address - Country:US
Mailing Address - Phone:989-781-6178
Mailing Address - Fax:
Practice Address - Street 1:2091 PROFESSIONAL DR
Practice Address - Street 2:SUITE I-1
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3657
Practice Address - Country:US
Practice Address - Phone:810-732-1652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401009990101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)