Healthcare Provider Details

I. General information

NPI: 1558969055
Provider Name (Legal Business Name): MICHAEL EVETTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2020
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 WOODLAWN AVE STE 15
O FALLON MO
63366-7647
US

IV. Provider business mailing address

6406 LAWNSIDE DRIVE
ST. LOUIS MO
63123
US

V. Phone/Fax

Practice location:
  • Phone: 636-379-1779
  • Fax:
Mailing address:
  • Phone: 314-435-8696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: