Provider Demographics
NPI:1538916267
Name:EVENCHIK, COURTNEY BROOKE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:BROOKE
Last Name:EVENCHIK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2526 LAFAYETTE DR
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44118-4608
Mailing Address - Country:US
Mailing Address - Phone:216-287-5773
Mailing Address - Fax:
Practice Address - Street 1:3659 GREEN RD STE 112
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5715
Practice Address - Country:US
Practice Address - Phone:216-896-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1274864103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool