Provider Demographics
NPI:1164860532
Name:EVANSON, TAMARA S (LICSW)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:S
Last Name:EVANSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:JEAN
Other - Last Name:SEVERANCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1037 WESTERN AVE
Mailing Address - Street 2:2ND FLOOR SUITE #3
Mailing Address - City:BRATTLEBORO
Mailing Address - State:VT
Mailing Address - Zip Code:05301-7133
Mailing Address - Country:US
Mailing Address - Phone:802-254-0088
Mailing Address - Fax:802-254-0088
Practice Address - Street 1:1037 WESTERN AVE
Practice Address - Street 2:2ND FLOOR SUITE #3
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-7133
Practice Address - Country:US
Practice Address - Phone:802-254-0088
Practice Address - Fax:802-254-0088
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-07
Last Update Date:2015-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT08900761581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical