MEDICARE: VENUS E EVANS-WINTERS LCSW, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149019806	IL

General Provider Information

NPI Number	:	1568934164
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VENUS E EVANS-WINTERS LCSW, PHD

Provider Business Mailing Address
First Line	:	PO BOX 9401
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61612-9401
Country	:	US
Telephone Number	:	309-453-0953
Fax Number	:

Provider Business Practice Location Address
First Line	:	4507 N STERLING AVE STE 201
Second Line	:
City	:	PEORIA
State	:	IL
Zip	:	61615-3861
Country	:	US
Telephone Number	:	309-362-0501
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/19/2018
Last Update Date	:	12/19/2018

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