Healthcare Provider Details

I. General information

NPI: 1568190536
Provider Name (Legal Business Name): EVANSON BEHAVIORAL HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 SPRING AVE
GLEN ELLYN IL
60137-4824
US

IV. Provider business mailing address

264 SPRING AVE
GLEN ELLYN IL
60137-4824
US

V. Phone/Fax

Practice location:
  • Phone: 630-750-6684
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE M EVANSON
Title or Position: CLINICAL THERAPIST AND FOUNDER
Credential: LCPC
Phone: 630-750-6684