Provider Demographics
NPI:1710719349
Name:SUMMASUP, EVAN
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:SUMMASUP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4041
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03302-4041
Mailing Address - Country:US
Mailing Address - Phone:617-819-0914
Mailing Address - Fax:
Practice Address - Street 1:1 BARBERRY LN
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2417
Practice Address - Country:US
Practice Address - Phone:617-819-0914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH4738101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health