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General NPI Number Information
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NPI Number | 1306227657
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Entity Type | Individual
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Provider Name | EVAN J DIVIS PLMHP
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Gender | Male
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Dates
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Enumeration Date | 06/12/2015
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Last Update Date | 06/12/2015
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Provider Practice Location Address
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Address Line | 245 S 84TH ST STE 212
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City | LINCOLN
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State | NE
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Zip | 68510-2600
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Country | US
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Telephone | 402-261-9273
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Fax | 402-261-9274
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Provider Business Mailing Address
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Address Line | PO BOX 1763
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City | GRAND ISLAND
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State | NE
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Zip | 68802-1763
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Country | US
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Telephone | 308-395-1067
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Fax | 308-395-1060
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 10533
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License Number State | NE
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