Provider Demographics
NPI:1124497987
Name:LONG, EVONNE MARIE (AUD)
Entity type:Individual
Prefix:
First Name:EVONNE
Middle Name:MARIE
Last Name:LONG
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:EVONNE
Other - Middle Name:MARIE
Other - Last Name:CLEVELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:1010 N DAVIS ST STE 101
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32209-6808
Mailing Address - Country:US
Mailing Address - Phone:904-355-3403
Mailing Address - Fax:904-355-4149
Practice Address - Street 1:1010 N DAVIS ST STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209
Practice Address - Country:US
Practice Address - Phone:904-355-3403
Practice Address - Fax:904-355-4149
Is Sole Proprietor?:No
Enumeration Date:2015-09-22
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC7987231H00000X
FLAY1974231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019346100Medicaid
FLAY1974OtherSTATE LICENSING BOARD