Provider Demographics
NPI:1316462674
Name:EVANS, ROBERT BRYAN
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:BRYAN
Last Name:EVANS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 S 12TH ST APT G
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-4339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 N 11TH ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1015
Practice Address - Country:US
Practice Address - Phone:314-231-3720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20170157661041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical