Provider Demographics
NPI:1316479017
Name:EVANS, JULIE KWON (PHD)
Entity type:Individual
Prefix:
First Name:JULIE
Middle Name:KWON
Last Name:EVANS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2125
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48012-2125
Mailing Address - Country:US
Mailing Address - Phone:773-963-1523
Mailing Address - Fax:
Practice Address - Street 1:74 W LONG LAKE RD # 28
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48304-2769
Practice Address - Country:US
Practice Address - Phone:773-963-1523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-31
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 103TE1100X, 103TH0004X, 133VN1004X, 174H00000X, 225700000X, 251B00000X, 261Q00000X, 343900000X, 390200000X
MIM719636171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103TE1100XBehavioral Health & Social Service ProvidersPsychologistExercise & Sports
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
No174H00000XOther Service ProvidersHealth Educator
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No251B00000XAgenciesCase Management
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program