Provider Demographics
NPI:1396114047
Name:EVANS, DEAN
Entity type:Individual
Prefix:
First Name:DEAN
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 1:1006 PHILLIPS ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-2712
Mailing Address - Country:US
Mailing Address - Phone:410-603-7570
Mailing Address - Fax:
Practice Address - Street 1:1006 PHILLIPS ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-2712
Practice Address - Country:US
Practice Address - Phone:410-603-7570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-23
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD10021951Medicaid