Provider Demographics
NPI:1124287032
Name:EVANS, AMELIA L (MS, LPC)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:L
Last Name:EVANS
Suffix:
Gender:F
Credentials:MS, LPC
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:L
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, LPC
Mailing Address - Street 1:2910 ENLOE ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:HUDSON
Mailing Address - State:WI
Mailing Address - Zip Code:54016-4538
Mailing Address - Country:US
Mailing Address - Phone:715-377-0000
Mailing Address - Fax:715-377-0010
Practice Address - Street 1:2910 ENLOE ST
Practice Address - Street 2:SUITE 104
Practice Address - City:HUDSON
Practice Address - State:WI
Practice Address - Zip Code:54016-4538
Practice Address - Country:US
Practice Address - Phone:715-377-0000
Practice Address - Fax:715-377-0010
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-05
Last Update Date:2008-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4061-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional