Provider Demographics
NPI:1477941565
Name:EVOLVE WITH KAREN COUNSELING SERVICE
Entity Type:Organization
Organization Name:EVOLVE WITH KAREN COUNSELING SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:MUNDT
Authorized Official - Suffix:
Authorized Official - Credentials:C-SAC
Authorized Official - Phone:715-305-8112
Mailing Address - Street 1:304 S. MAIN STREET
Mailing Address - Street 2:UNIT F
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1845
Mailing Address - Country:US
Mailing Address - Phone:715-305-8112
Mailing Address - Fax:715-748-0208
Practice Address - Street 1:304 S MAIN ST
Practice Address - Street 2:UNIT F
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1845
Practice Address - Country:US
Practice Address - Phone:715-305-8112
Practice Address - Fax:715-748-0208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-26
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39385400Medicaid