MEDICARE: MRS. JOHANNA MARIA EVENSON LISW-CP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	8539	SC

General Provider Information

NPI Number	:	1225296718
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JOHANNA MARIA EVENSON LISW-CP

Provider Business Mailing Address
First Line	:	214 WENTWORTH ST
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29401-1252
Country	:	US
Telephone Number	:	843-259-8013
Fax Number	:

Provider Business Practice Location Address
First Line	:	48 HASELL ST
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29401-1616
Country	:	US
Telephone Number	:	843-259-8013
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2008
Last Update Date	:	05/30/2008

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