1124087481 NPI number — MRS. MECHELE DE AVILA EVANS LCSW

Table of content: MRS. MECHELE DE AVILA EVANS LCSW (NPI 1124087481)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124087481 NPI number — MRS. MECHELE DE AVILA EVANS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
MECHELE
Provider Middle Name:
DE AVILA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DE AVILA
Provider Other First Name:
MECHELE
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1124087481
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 41001
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BATON ROUGE
Provider Business Mailing Address State Name:
LA
Provider Business Mailing Address Postal Code:
70835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
225-366-8606
Provider Business Mailing Address Fax Number:
225-410-0080

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1082 HAVENWOOD DRIVE
Provider Second Line Business Practice Location Address:
BACK APARTMENT
Provider Business Practice Location Address City Name:
BATON ROUGE
Provider Business Practice Location Address State Name:
LA
Provider Business Practice Location Address Postal Code:
70815-6730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
225-366-8606
Provider Business Practice Location Address Fax Number:
225-410-0080
Provider Enumeration Date:
03/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  40065 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1549495 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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