Provider Demographics
NPI:1386060127
Name:EVANS, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37378 CHARTER OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48036
Mailing Address - Country:US
Mailing Address - Phone:313-300-4197
Mailing Address - Fax:
Practice Address - Street 1:5575 CONNER ST
Practice Address - Street 2:SUITE 201 PAVILION BUILDING
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-6400
Practice Address - Country:US
Practice Address - Phone:313-300-4197
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-17
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014129101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional