Healthcare Provider Details

I. General information

NPI: 1093725806
Provider Name (Legal Business Name): MARK CHRISTOPHER EVANS LCPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 EUSTIS PKWY
WATERVILLE ME
04901-5173
US

IV. Provider business mailing address

67 EUSTIS PKWY
WATERVILLE ME
04901-5173
US

V. Phone/Fax

Practice location:
  • Phone: 207-873-2136
  • Fax: 207-872-4522
Mailing address:
  • Phone: 207-873-2136
  • Fax: 207-872-4522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCC2237
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: