Healthcare Provider Details

I. General information

NPI: 1124287032
Provider Name (Legal Business Name): AMELIA L EVANS M.S., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AMY L EVANS M.S., LPC

II. Dates (important events)

Enumeration Date: 06/05/2008
Last Update Date: 12/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2910 ENLOE ST SUITE 104
HUDSON WI
54016-4538
US

IV. Provider business mailing address

2910 ENLOE ST SUITE 104
HUDSON WI
54016-4538
US

V. Phone/Fax

Practice location:
  • Phone: 715-377-0000
  • Fax: 715-377-0010
Mailing address:
  • Phone: 715-377-0000
  • Fax: 715-377-0010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number4061-125
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: