Healthcare Provider Details

I. General information

NPI: 1952196628
Provider Name (Legal Business Name): JULIE EVENSON LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2025
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MARKET ST STE 4A
WINONA MN
55987-5532
US

IV. Provider business mailing address

111 MARKET ST STE 4A
WINONA MN
55987-5532
US

V. Phone/Fax

Practice location:
  • Phone: 507-452-5033
  • Fax:
Mailing address:
  • Phone: 507-452-5033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304312
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: