Provider Demographics
NPI:1851179725
Name:MOCK, EVALENA KAYE (LMT)
Entity Type:Individual
Prefix:MRS
First Name:EVALENA
Middle Name:KAYE
Last Name:MOCK
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1304 S JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PERRY
Mailing Address - State:FL
Mailing Address - Zip Code:32348-4731
Mailing Address - Country:US
Mailing Address - Phone:850-371-4395
Mailing Address - Fax:
Practice Address - Street 1:1304 S JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:FL
Practice Address - Zip Code:32348-4731
Practice Address - Country:US
Practice Address - Phone:850-371-4395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-20
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA97342225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist