MEDICARE: CONNIE S EVANS LMHC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YS0200X	School Counselor		FL
2	101YM0800X	Mental Health Counselor	MH8020	FL

General Provider Information

NPI Number	:	1891957775
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONNIE S EVANS LMHC

Provider Business Mailing Address
First Line	:	109 PINEAPPLE ST E
Second Line	:	PO BOX 1039
City	:	BOWLING GREEN
State	:	FL
Zip	:	33834-1039
Country	:	US
Telephone Number	:	863-375-4052
Fax Number	:

Provider Business Practice Location Address
First Line	:	109 PINEAPPLE ST E
Second Line	:
City	:	BOWLING GREEN
State	:	FL
Zip	:	33834-1039
Country	:	US
Telephone Number	:	863-375-4052
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/01/2008
Last Update Date	:	07/03/2008

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Directions to “ CONNIE S EVANS LMHC” Practice Location

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