Provider Demographics
NPI:1740243062
Name:EVANS, BLAKE ANDREW (PHD,LP)
Entity type:Individual
Prefix:
First Name:BLAKE
Middle Name:ANDREW
Last Name:EVANS
Suffix:
Gender:M
Credentials:PHD,LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 17TH AVE E
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3703
Mailing Address - Country:US
Mailing Address - Phone:320-762-1511
Mailing Address - Fax:
Practice Address - Street 1:700 CEDAR ST
Practice Address - Street 2:STE 154
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-1769
Practice Address - Country:US
Practice Address - Phone:320-762-2400
Practice Address - Fax:320-762-8047
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4493103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN928011035317OtherPREFERREDONE
MN408T0EVOtherBLUECROSS/BLUESHIELD
MNHP49914OtherHEALTHPARTNERS