Provider Demographics
NPI:1386979177
Name:CONLEY, EVELYN FAYE
Entity type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:FAYE
Last Name:CONLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2309 JAMES ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-4370
Mailing Address - Country:US
Mailing Address - Phone:269-806-6315
Mailing Address - Fax:269-388-4439
Practice Address - Street 1:112 E CHART ST
Practice Address - Street 2:
Practice Address - City:PLAINWELL
Practice Address - State:MI
Practice Address - Zip Code:49080-1768
Practice Address - Country:US
Practice Address - Phone:269-685-6363
Practice Address - Fax:269-685-5995
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1518448101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI59-3795383Medicaid
MI59-3795383Medicare UPIN
MI59-3795383Medicaid