Provider Demographics
NPI:1902233299
Name:EVANS, BLYTHE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:BLYTHE
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 RED BARN LN
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-3700
Mailing Address - Country:US
Mailing Address - Phone:203-775-4294
Mailing Address - Fax:203-346-6119
Practice Address - Street 1:12 RED BARN LN
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:CT
Practice Address - Zip Code:06804-3700
Practice Address - Country:US
Practice Address - Phone:203-775-4294
Practice Address - Fax:203-346-6119
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0068141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical