Provider Demographics
NPI:1679770622
Name:EVANS, MARY LEE (LMFT)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:EVANS
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 DALE EARNHARDT BLVD
Mailing Address - Street 2:
Mailing Address - City:KANNAPOLIS
Mailing Address - State:NC
Mailing Address - Zip Code:28083-3210
Mailing Address - Country:US
Mailing Address - Phone:252-944-6264
Mailing Address - Fax:704-655-2799
Practice Address - Street 1:1630 DALE EARNHARDT BLVD
Practice Address - Street 2:
Practice Address - City:KANNAPOLIS
Practice Address - State:NC
Practice Address - Zip Code:28083-3210
Practice Address - Country:US
Practice Address - Phone:252-944-6264
Practice Address - Fax:704-655-2799
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NC5025A106H00000X
NC1218106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health