Provider Demographics
NPI:1952483273
Name:EVERSON, BRUCE M (CSAC, SAP)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
Last Name:EVERSON
Suffix:
Gender:M
Credentials:CSAC, SAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2620 STEIN BLVD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6201
Mailing Address - Country:US
Mailing Address - Phone:715-836-0064
Mailing Address - Fax:715-836-0065
Practice Address - Street 1:2620 STEIN BLVD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6201
Practice Address - Country:US
Practice Address - Phone:715-836-0064
Practice Address - Fax:715-836-0065
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1997101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39364700Medicaid