Provider Demographics
NPI:1245855576
Name:EVANS, ELIZABETH
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:186 HIBISCUS RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32141-7216
Mailing Address - Country:US
Mailing Address - Phone:407-832-8175
Mailing Address - Fax:
Practice Address - Street 1:500 CANAL ST
Practice Address - Street 2:
Practice Address - City:NEW SMYRNA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32168-7012
Practice Address - Country:US
Practice Address - Phone:407-832-8175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-12
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT3538106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty