Provider Demographics
NPI:1508408733
Name:EVANS, MICHAEL (LLPC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36002 HUNTER AVE APT 11315
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-6650
Mailing Address - Country:US
Mailing Address - Phone:313-460-4439
Mailing Address - Fax:
Practice Address - Street 1:36002 HUNTER AVE APT 11315
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-6650
Practice Address - Country:US
Practice Address - Phone:313-460-4439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017779101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health