Basic Information
| Provider Information | |||||||||
| NPI: | 1255789632 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | LPC, MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 W OLIVE ST | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805212716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703103406 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 320 W OLIVE ST | ||||||||
| Address2: | |||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 80521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703103406 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2016 | ||||||||
| LastUpdateDate: | 09/06/2019 | ||||||||
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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 | 101YP2500X | LPC.0015327 | CO | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | 180.004735 | IL | N | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.