Healthcare Provider Details

I. General information

NPI: 1366824427
Provider Name (Legal Business Name): STEPHENE LORAN EVANS LISW, OCPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 11/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1832 ADAMS ST
TOLEDO OH
43604-4428
US

IV. Provider business mailing address

5666 CLOVER LN
WALBRIDGE OH
43465-9595
US

V. Phone/Fax

Practice location:
  • Phone: 419-214-0606
  • Fax:
Mailing address:
  • Phone: 734-644-3543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1901792
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code405300000X
TaxonomyPrevention Professional
License NumberOCPC.161315
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: