Provider Demographics
NPI:1962488783
Name:EVERMON, AMY NICOLE (MSED)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:NICOLE
Last Name:EVERMON
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:MISS
Other - First Name:AMY
Other - Middle Name:NICOLE
Other - Last Name:BRAULT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:750 BROADWAY AVE E
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4610
Mailing Address - Country:US
Mailing Address - Phone:217-238-5700
Mailing Address - Fax:217-238-5767
Practice Address - Street 1:750 BROADWAY AVE E
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-4610
Practice Address - Country:US
Practice Address - Phone:217-238-5700
Practice Address - Fax:217-238-5767
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor