Healthcare Provider Details

I. General information

NPI: 1891325361
Provider Name (Legal Business Name): THERESA EVANOFF MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 COBUN CREEK RD
MORGANTOWN WV
26508-3832
US

IV. Provider business mailing address

418 COBUN CREEK RD
MORGANTOWN WV
26508-3832
US

V. Phone/Fax

Practice location:
  • Phone: 304-614-4323
  • Fax:
Mailing address:
  • Phone: 304-614-4323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1244
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1244
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: