Provider Demographics
NPI:1316338502
Name:EVANS, MARISA L (LPC)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:L
Last Name:EVANS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARISA
Other - Middle Name:L
Other - Last Name:LEISTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 22040
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2040
Mailing Address - Country:US
Mailing Address - Phone:920-445-7210
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:3263 EATON RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6830
Practice Address - Country:US
Practice Address - Phone:920-433-6700
Practice Address - Fax:920-433-6738
Is Sole Proprietor?:No
Enumeration Date:2015-02-10
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6408-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional