Provider Demographics
NPI:1982611968
Name:MAW, EVAN LYLE (LCSW)
Entity type:Individual
Prefix:
First Name:EVAN
Middle Name:LYLE
Last Name:MAW
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-2336
Mailing Address - Country:US
Mailing Address - Phone:559-784-0312
Mailing Address - Fax:559-784-5827
Practice Address - Street 1:409 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTERVILLE
Practice Address - State:CA
Practice Address - Zip Code:93257-2336
Practice Address - Country:US
Practice Address - Phone:559-784-0312
Practice Address - Fax:559-784-5827
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS65511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ86705ZMedicare ID - Type Unspecified