Provider Demographics
NPI:1669499653
Name:VIZZINI, EVANGELINE EVE (MED,LPC)
Entity Type:Individual
Prefix:MS
First Name:EVANGELINE
Middle Name:EVE
Last Name:VIZZINI
Suffix:
Gender:F
Credentials:MED,LPC
Other - Prefix:MS
Other - First Name:EVANGELINE
Other - Middle Name:EVE
Other - Last Name:DOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED,LPC
Mailing Address - Street 1:1600 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-3603
Mailing Address - Country:US
Mailing Address - Phone:228-863-1132
Mailing Address - Fax:228-865-1700
Practice Address - Street 1:1600 BROAD AVE
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-3603
Practice Address - Country:US
Practice Address - Phone:228-863-1132
Practice Address - Fax:228-865-1700
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1133101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00018213Medicaid