Basic Information
| Provider Information | |||||||||
| NPI: | 1043262793 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 515 BAYOU ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128866800 | ||||||||
| FaxNumber: | 8128866809 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 BUNTIN ST | ||||||||
| Address2: | |||||||||
| City: | VINCENNES | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475911320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8128852700 | ||||||||
| FaxNumber: | 8128852716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 34004332A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 326003 | 01 | IN | VALUEOPTIONS GROUP NUMBER | OTHER |