Basic Information
| Provider Information | |||||||||
| NPI: | 1609042589 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | B | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 2ND ST | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | SAINT MARYS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261701097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046842656 | ||||||||
| FaxNumber: | 3046842658 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 2ND ST | ||||||||
| Address2: | SUITE 6 | ||||||||
| City: | SAINT MARYS | ||||||||
| State: | WV | ||||||||
| PostalCode: | 261701097 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046842656 | ||||||||
| FaxNumber: | 3046842658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2008 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | AP00942197 | WV | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.