Basic Information
Provider Information | |||||||||
NPI: | 1679522494 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EVENSON | ||||||||
FirstName: | KAREN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MS LPC CADC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 281 | ||||||||
Address2: |   | ||||||||
City: | BARABOO | ||||||||
State: | WI | ||||||||
PostalCode: | 53913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083569665 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 635 15TH ST | ||||||||
Address2: |   | ||||||||
City: | BARABOO | ||||||||
State: | WI | ||||||||
PostalCode: | 53913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6083569884 | ||||||||
FaxNumber: | 6083560985 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 2980-125 | WI | X |   | Behavioral Health & Social Service Providers | Counselor |   | 101YA0400X | 10502 | WI | X |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YM0800X | 2980-125 | WI | X |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 43575800 | 05 | WI |   | MEDICAID |