MEDICARE: MR. PAUL THOMAS EVANS CADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	30531	IL

General Provider Information

NPI Number	:	1720498769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PAUL THOMAS EVANS CADC

Provider Business Mailing Address
First Line	:	3936 W ROOSEVELT RD
Second Line	:	SUITE 2
City	:	CHICAGO
State	:	IL
Zip	:	60624-4389
Country	:	US
Telephone Number	:	773-826-0398
Fax Number	:

Provider Business Practice Location Address
First Line	:	3936 W ROOSEVELT RD
Second Line	:	SUITE 2
City	:	CHICAGO
State	:	IL
Zip	:	60624-4389
Country	:	US
Telephone Number	:	773-826-0398
Fax Number	:

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

Provider Enumeration Date	:	04/29/2014
Last Update Date	:	04/29/2014

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