Provider Demographics
NPI:1578820312
Name:EVONNE, TAMARA (LCSW)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:EVONNE
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 1:1485 S SEMORAN BLVD STE 1448
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32792-5508
Mailing Address - Country:US
Mailing Address - Phone:321-397-3000
Mailing Address - Fax:
Practice Address - Street 1:711 NW 1ST ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32601-5343
Practice Address - Country:US
Practice Address - Phone:904-966-1056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-18
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW 106741041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical