Healthcare Provider Details

I. General information

NPI: 1912740093
Provider Name (Legal Business Name): ALEXANDER LENNON EVANS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 W 13 MILE RD
ROYAL OAK MI
48073-6515
US

IV. Provider business mailing address

3442 BENT TRAIL DR
ANN ARBOR MI
48108-9302
US

V. Phone/Fax

Practice location:
  • Phone: 248-549-4339
  • Fax:
Mailing address:
  • Phone: 734-352-7515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberE152044506384
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: