Provider Demographics
NPI:1386408177
Name:EVERTZ WILCOX, MARY ANNE
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANNE
Last Name:EVERTZ WILCOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ANNE
Other - Last Name:EVERTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4692 OLD GUERNSEY RD
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32571-8682
Mailing Address - Country:US
Mailing Address - Phone:850-602-8080
Mailing Address - Fax:
Practice Address - Street 1:217 MIRACLE STRIP PKWY SE
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32548-5819
Practice Address - Country:US
Practice Address - Phone:850-861-7171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-12
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW199881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical