Provider Demographics
NPI:1891325361
Name:EVANOFF, THERESA (MS)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:EVANOFF
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 COBUN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-3832
Mailing Address - Country:US
Mailing Address - Phone:304-614-4323
Mailing Address - Fax:
Practice Address - Street 1:418 COBUN CREEK RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-3832
Practice Address - Country:US
Practice Address - Phone:304-614-4323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-23
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1244103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical