Provider Demographics
NPI:1407861867
Name:KIRKMAN, EVELYN DIANE (LCSW)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:DIANE
Last Name:KIRKMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 S MAIN ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-2445
Mailing Address - Country:US
Mailing Address - Phone:860-521-7111
Mailing Address - Fax:860-561-6184
Practice Address - Street 1:68 S MAIN ST
Practice Address - Street 2:SUITE 202
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2445
Practice Address - Country:US
Practice Address - Phone:860-521-7111
Practice Address - Fax:860-561-6184
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0001081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT140000108CT04OtherANTHEM BCBS PROVIDER #
CT079556OtherMHN PROVIDER #
CT800001751Medicare ID - Type Unspecified