Provider Demographics
NPI:1225296718
Name:EVENSON, JOHANNA MARIA (LISW-CP)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:MARIA
Last Name:EVENSON
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 WENTWORTH ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29401-1252
Mailing Address - Country:US
Mailing Address - Phone:843-259-8013
Mailing Address - Fax:
Practice Address - Street 1:48 HASELL ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1616
Practice Address - Country:US
Practice Address - Phone:843-259-8013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC85391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical