Provider Demographics
NPI:1104122605
Name:EVENSEN, LAURA LOUISE (LICSW)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LOUISE
Last Name:EVENSEN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5917 DUPONT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55419-2110
Mailing Address - Country:US
Mailing Address - Phone:952-232-9933
Mailing Address - Fax:651-925-0433
Practice Address - Street 1:4306 BRYANT AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55409-1709
Practice Address - Country:US
Practice Address - Phone:952-649-6826
Practice Address - Fax:652-925-0433
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN193851041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical