Provider Demographics
NPI:1841356656
Name:EVANS, WENDY JO (MSSW)
Entity type:Individual
Prefix:MS
First Name:WENDY
Middle Name:JO
Last Name:EVANS
Suffix:
Gender:F
Credentials:MSSW
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 134
Mailing Address - Street 2:
Mailing Address - City:MACHIAS
Mailing Address - State:ME
Mailing Address - Zip Code:04654-0134
Mailing Address - Country:US
Mailing Address - Phone:207-255-4600
Mailing Address - Fax:207-255-4602
Practice Address - Street 1:17 STACKPOLE DR
Practice Address - Street 2:STE 3
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654-7000
Practice Address - Country:US
Practice Address - Phone:207-255-4600
Practice Address - Fax:207-255-4602
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME#LC34981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME328970099Medicaid