Basic Information
| Provider Information | |||||||||
| NPI: | 1215372305 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | KYARA | ||||||||
| MiddleName: | RENE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLBSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40480 | ||||||||
| Address2: | |||||||||
| City: | REDFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482400480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132582974 | ||||||||
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| Practice Location | |||||||||
| Address1: | 13101 ALLEN RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2013 | ||||||||
| LastUpdateDate: | 05/03/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802086934 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.