Healthcare Provider Details

I. General information

NPI: 1609792431
Provider Name (Legal Business Name): MARY CAROLINE EVANGELISTI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3964 GOODMAN RD E STE 105
SOUTHAVEN MS
38672-8711
US

IV. Provider business mailing address

2188 DOGWOOD OAKS DR
GERMANTOWN TN
38139-5303
US

V. Phone/Fax

Practice location:
  • Phone: 662-932-4625
  • Fax: 662-932-4626
Mailing address:
  • Phone: 901-232-7679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5545
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: