MEDICARE: MR. ROBERT MARK EVANS LCSW, ACSW

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	19475	TX
2	1041C0700X	Clinical Social Worker	R0413121	NY

General Provider Information

NPI Number	:	1770606972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT MARK EVANS LCSW, ACSW

Provider Business Mailing Address
First Line	:	3600 MONTROSE BLVD
Second Line	:	UNIT 1103
City	:	HOUSTON
State	:	TX
Zip	:	77006-4658
Country	:	US
Telephone Number	:	713-447-2656
Fax Number	:

Provider Business Practice Location Address
First Line	:	1155 PRESSLER ST
Second Line	:	UT MD ANDERSON CANCER PREVENTION BLDG UNIT 1330
City	:	HOUSTON
State	:	TX
Zip	:	77030-3721
Country	:	US
Telephone Number	:	713-792-5927
Fax Number	:

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

Provider Enumeration Date	:	04/10/2007
Last Update Date	:	07/08/2007

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