Provider Demographics
NPI:1841513801
Name:EVANS, MICHELLE R (LCSW)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
Last Name:EVANS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 CONWAY LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60503-8548
Mailing Address - Country:US
Mailing Address - Phone:630-244-5952
Mailing Address - Fax:
Practice Address - Street 1:155 BOULDER HILL PASS
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538-2305
Practice Address - Country:US
Practice Address - Phone:630-844-3001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0122041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical