=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992375836
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARAH ELIZABETH EVANS MSW, LGSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2021
-----------------------------------------------------
Last Update Date | 07/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 502 E 2ND ST
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55805-1913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-786-8364
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | SSB-6 400 E 3RD ST
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55805-1951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-786-8364
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 38969
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------