Basic Information
| Provider Information | |||||||||
| NPI: | 1982773578 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVENSON | ||||||||
| FirstName: | MERLE | ||||||||
| MiddleName: | BRIAN | ||||||||
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| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 151 S 4TH ST | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582014715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017953000 | ||||||||
| FaxNumber: | 7017953050 | ||||||||
| Practice Location | |||||||||
| Address1: | 151 S 4TH ST | ||||||||
| Address2: | SUITE 401 | ||||||||
| City: | GRAND FORKS | ||||||||
| State: | ND | ||||||||
| PostalCode: | 582014715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7017953000 | ||||||||
| FaxNumber: | 7017953050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 821 | ND | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 054519 | 05 | ND | MEDICAID |