Basic Information
| Provider Information | |||||||||
| NPI: | 1023177201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | LEROY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MASTER SOCIAL WORK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5285 COUNTY ROAD 4 NE | ||||||||
| Address2: | |||||||||
| City: | ATWATER | ||||||||
| State: | MN | ||||||||
| PostalCode: | 56209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202354613 | ||||||||
| FaxNumber: | 3202319140 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 6TH STREET SE | ||||||||
| Address2: | WOODLAND CENTERS | ||||||||
| City: | WILLMAR | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562014675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202319148 | ||||||||
| FaxNumber: | 3202319140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 391 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1013109 | 01 | PREFERRED ONE | OTHER | 115671 | 01 | UCARE | OTHER | 30024EV | 01 | BLUE CROSS | OTHER | 6220225 | 01 | UBH | OTHER |