Provider Demographics
NPI:1477088631
Name:EVANS, STEPHANIE (LCSW)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4937 US HIGHWAY 98 N # 9101
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33809-3610
Mailing Address - Country:US
Mailing Address - Phone:813-527-8976
Mailing Address - Fax:
Practice Address - Street 1:3280 MITCHELL BLVD
Practice Address - Street 2:
Practice Address - City:MOODY AFB
Practice Address - State:GA
Practice Address - Zip Code:31699-1580
Practice Address - Country:US
Practice Address - Phone:229-257-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW16883102L00000X, 104100000X, 1041C0700X
101YM0800X
FLISW11019102X00000X, 1041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No102X00000XBehavioral Health & Social Service ProvidersPoetry Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL112077100Medicaid