Basic Information
| Provider Information | |||||||||
| NPI: | 1144348996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVENDEN | ||||||||
| FirstName: | JEREMY | ||||||||
| MiddleName: | |||||||||
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| Credential: | L.I.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32604 REDWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | AVON LAKE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440121629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409304346 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6140 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440533821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4402044100 | ||||||||
| FaxNumber: | 4402334468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2007 | ||||||||
| 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 | 104100000X | I-0026820 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.