Provider Demographics
NPI:1063758340
Name:EVANS, KATHLEEN MCCREA (LCPC)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MCCREA
Last Name:EVANS
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:78 ATLANTIC PLACE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-2316
Mailing Address - Country:US
Mailing Address - Phone:207-661-6654
Mailing Address - Fax:207-842-7773
Practice Address - Street 1:11 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2690
Practice Address - Country:US
Practice Address - Phone:207-373-9417
Practice Address - Fax:207-373-9418
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-14
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECC4671101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional