Healthcare Provider Details

I. General information

NPI: 1083092878
Provider Name (Legal Business Name): CICELY EVERSON MH, CFMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2015
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 CHESTERFIELD DR
NEW CASTLE DE
19720-1220
US

IV. Provider business mailing address

18199 BEAVER DAM RD
LEWES DE
19958-4535
US

V. Phone/Fax

Practice location:
  • Phone: 302-275-6879
  • Fax:
Mailing address:
  • Phone: 302-344-1789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number000000
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number000000
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number StateDE
# 4
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: