Provider Demographics
NPI:1124145107
Name:EVANS, ROBERT GALE (LCSW)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:GALE
Last Name:EVANS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4294 S JORDAN DR
Mailing Address - Street 2:
Mailing Address - City:MC FARLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53558-9057
Mailing Address - Country:US
Mailing Address - Phone:608-835-5980
Mailing Address - Fax:
Practice Address - Street 1:289 IRELAND AVE
Practice Address - Street 2:IRELAND ARMY COMMUNITY HOSPITAL CAMP ATTERBURY
Practice Address - City:FORT KNOX
Practice Address - State:KY
Practice Address - Zip Code:40121-5111
Practice Address - Country:US
Practice Address - Phone:502-642-9007
Practice Address - Fax:502-624-0252
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2713-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical