Provider Demographics
NPI:1699258111
Name:EVANICH, CASSIDY NOELLE (LCSW, SAC)
Entity type:Individual
Prefix:MRS
First Name:CASSIDY
Middle Name:NOELLE
Last Name:EVANICH
Suffix:
Gender:F
Credentials:LCSW, SAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16535 W BLUEMOUND RD STE 200
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5906
Mailing Address - Country:US
Mailing Address - Phone:414-293-0236
Mailing Address - Fax:262-821-6180
Practice Address - Street 1:16535 W BLUEMOUND RD STE 200
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5906
Practice Address - Country:US
Practice Address - Phone:414-293-0236
Practice Address - Fax:262-821-6180
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
WI9585-1231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator