Provider Demographics
NPI:1104121185
Name:FOSTER, EVON NICOLE (LLMSW)
Entity type:Individual
Prefix:MRS
First Name:EVON
Middle Name:NICOLE
Last Name:FOSTER
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18516 ARCHDALE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-3265
Mailing Address - Country:US
Mailing Address - Phone:313-850-7818
Mailing Address - Fax:313-694-3155
Practice Address - Street 1:18516 ARCHDALE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-3265
Practice Address - Country:US
Practice Address - Phone:313-850-7818
Practice Address - Fax:313-255-4028
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-21
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801087359104100000X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker