Healthcare Provider Details

I. General information

NPI: 1588011993
Provider Name (Legal Business Name): OPAL EVANS LCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2016
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 MAIN ST STE 202
PRINCE FREDERICK MD
20678-6150
US

IV. Provider business mailing address

PO BOX 2246
PRINCE FREDERICK MD
20678-2246
US

V. Phone/Fax

Practice location:
  • Phone: 443-295-3137
  • Fax:
Mailing address:
  • Phone: 573-239-0554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC9835
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: