Healthcare Provider Details

I. General information

NPI: 1699566133
Provider Name (Legal Business Name): EVAN JOHN OHARA LLC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2025
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1460 WALTON BLVD
ROCHESTER HILLS MI
48309-1768
US

IV. Provider business mailing address

475 W BRECKENRIDGE ST
FERNDALE MI
48220-1745
US

V. Phone/Fax

Practice location:
  • Phone: 248-608-4514
  • Fax:
Mailing address:
  • Phone: 248-496-0334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451024357
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: