Provider Demographics
NPI:1740029040
Name:EVENSEN, MATYSEN LEONE (CSW)
Entity type:Individual
Prefix:
First Name:MATYSEN
Middle Name:LEONE
Last Name:EVENSEN
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 VALERIA DR
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-3312
Mailing Address - Country:US
Mailing Address - Phone:385-505-3739
Mailing Address - Fax:
Practice Address - Street 1:880 HERITAGE PARK BLVD STE 230
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5675
Practice Address - Country:US
Practice Address - Phone:385-393-4057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical