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General NPI Number Information
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NPI Number | 1114689379
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Entity Type | Organization
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Legal Business Name | EVCA, LLC
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Dates
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Enumeration Date | 10/05/2021
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Last Update Date | 10/05/2021
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Provider Practice Location Address
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Address Line | 5355 NEWBERRY ST
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City | WAYNE
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State | MI
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Zip | 48184-2305
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Country | US
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Telephone | 313-207-3057
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Fax |
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Provider Business Mailing Address
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Address Line | 5355 NEWBERRY ST
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City | WAYNE
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State | MI
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Zip | 48184-2305
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Country | US
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Telephone | 313-207-3057
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Fax |
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Authorized Official
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Title or Position | OWNER/CHIEF EXECUTIVE OFFICER
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Name | MRS. EVETTE N CARROLL
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Credential | LMSW
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Telephone | 313-207-3057
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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