Provider Demographics
NPI:1952966046
Name:EVANS, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 INGLE ST
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47708-1345
Mailing Address - Country:US
Mailing Address - Phone:812-602-4022
Mailing Address - Fax:
Practice Address - Street 1:629 INGLE ST
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47708-1345
Practice Address - Country:US
Practice Address - Phone:812-602-4022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-05
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
IN1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201403210AMedicaid