Provider Demographics
NPI:1447264015
Name:EVANS, MICHELLE RENEE (MA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RENEE
Last Name:EVANS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HIDDEN SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-5090
Mailing Address - Country:US
Mailing Address - Phone:864-266-3393
Mailing Address - Fax:
Practice Address - Street 1:1 HIDDEN SPRINGS RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-5090
Practice Address - Country:US
Practice Address - Phone:864-266-3393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5012101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC301100Medicaid
SC301100Medicaid