Provider Demographics
NPI:1073080974
Name:ANASTOS, EVELYN JUNGHYUN (LCSW)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:JUNGHYUN
Last Name:ANASTOS
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 1:612 RIDGELINE DR UNIT 221
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-9463
Mailing Address - Country:US
Mailing Address - Phone:732-754-0434
Mailing Address - Fax:
Practice Address - Street 1:612 RIDGELINE DR UNIT 221
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-9463
Practice Address - Country:US
Practice Address - Phone:732-754-0434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2024-11-27
Deactivation Date:2020-05-05
Deactivation Code:
Reactivation Date:2020-05-20
Provider Licenses
StateLicense IDTaxonomies
NY0922781041C0700X
SC171361041C0700X
NCC0175651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty