Provider Demographics
NPI:1801105341
Name:THOMAS EVANS, AMANDA MARIE (PHD LPC NCC)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MARIE
Last Name:THOMAS EVANS
Suffix:
Gender:F
Credentials:PHD LPC NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 MAIN ST E
Mailing Address - Street 2:PO BOX 470
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-2735
Mailing Address - Country:US
Mailing Address - Phone:715-231-2702
Mailing Address - Fax:715-232-5987
Practice Address - Street 1:808 MAIN ST E
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-2735
Practice Address - Country:US
Practice Address - Phone:715-231-2702
Practice Address - Fax:715-232-5987
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TC1900X
WI925-226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional