MEDICARE: MS. DONA CECELIA EVANS LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	10084	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	62-31157	OTHER	MN	UNITED BEHAVIORAL HEALTH

General Provider Information

NPI Number	:	1760682207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. DONA CECELIA EVANS LICSW

Provider Business Mailing Address
First Line	:	3041 CEDAR AVE. SOUTH
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-4733
Country	:	US
Telephone Number	:	612-724-4212
Fax Number	:	612-825-6666

Provider Business Practice Location Address
First Line	:	3111 1ST AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55408-3136
Country	:	US
Telephone Number	:	612-767-6652
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/23/2007
Last Update Date	:	07/23/2007

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