Healthcare Provider Details

I. General information

NPI: 1124804315
Provider Name (Legal Business Name): ELIZA LYNN EVANGELISTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2023
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4997 ROYAL GULF CIRCLE
FORT MYERS FL
33966
US

IV. Provider business mailing address

4997 ROYAL GULF CIRCLE
FORT MYERS FL
33966
US

V. Phone/Fax

Practice location:
  • Phone: 239-313-5049
  • Fax: 239-313-5712
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-304725
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: