Provider Demographics
NPI:1639536014
Name:EVERSON, AMY
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:EVERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2236 COMMONWEALTH AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53726-5360
Mailing Address - Country:US
Mailing Address - Phone:608-213-2742
Mailing Address - Fax:
Practice Address - Street 1:2236 COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53726-5360
Practice Address - Country:US
Practice Address - Phone:608-213-2742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-15
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI415-228106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist