Provider Demographics
NPI:1215940986
Name:EVANS, MARION D (LMSW)
Entity type:Individual
Prefix:
First Name:MARION
Middle Name:D
Last Name:EVANS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 SOUTH SEVENTH STREET
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-0000
Mailing Address - Country:US
Mailing Address - Phone:734-645-5349
Mailing Address - Fax:
Practice Address - Street 1:1817 WEST STADIUM BLVD, SUITE E
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-0000
Practice Address - Country:US
Practice Address - Phone:734-645-5349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2011-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801019125101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0899924OtherBCBS
MIMI4399Medicare PIN