Healthcare Provider Details

I. General information

NPI: 1841651296
Provider Name (Legal Business Name): EVA GLEASON CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2016
Last Update Date: 03/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 SAINT ANDREW ST
LA CROSSE WI
54603-3301
US

IV. Provider business mailing address

11122 COUNTY ROAD 10
CALEDONIA MN
55921
US

V. Phone/Fax

Practice location:
  • Phone: 608-785-6266
  • Fax:
Mailing address:
  • Phone: 507-450-2073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number11969-120
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: