Provider Demographics
NPI:1952381816
Name:WEST, EVAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:WEST
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25351 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1784
Mailing Address - Country:US
Mailing Address - Phone:248-821-7374
Mailing Address - Fax:248-471-1212
Practice Address - Street 1:20010 FARMINGTON RD
Practice Address - Street 2:BLDG F
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1408
Practice Address - Country:US
Practice Address - Phone:248-821-7374
Practice Address - Fax:248-471-1212
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009467103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIS42357Medicare UPIN
MI0N30770Medicare ID - Type UnspecifiedPSYCHOLOGIST