Provider Demographics
NPI:1346701430
Name:FELTON, EVELYN L
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:L
Last Name:FELTON
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 1:16614 N DALE MABRY HWY
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33618
Mailing Address - Country:US
Mailing Address - Phone:813-838-0630
Mailing Address - Fax:
Practice Address - Street 1:4144 N ARMENIA AVE STE 350
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6434
Practice Address - Country:US
Practice Address - Phone:941-241-0872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-29
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106E00000X
FLIMH1603101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIMH16103OtherSTATE OF FLORIDA