Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 22067 | IL |
NPI | 1003042011 |
---|---|
Provider Name | Mr. Dave Scott Evans |
First Address | Carbondale, IL 62901 |
Second Address | Carbondale, IL 62901 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/06/2009 |
Last Update Date | 04/06/2009 |