Provider Demographics
NPI:1477088631
Name:EVANS, STEPHANIE (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 ARBOR GLEN CIR APT 201
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-2283
Mailing Address - Country:US
Mailing Address - Phone:813-527-8976
Mailing Address - Fax:
Practice Address - Street 1:8910 N DALE MABRY HWY STE 2
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-1580
Practice Address - Country:US
Practice Address - Phone:813-527-8976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW16883102L00000X, 104100000X, 1041C0700X
101YM0800X
FLISW11019102X00000X, 1041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112077100Medicaid