Provider Demographics
NPI:1427095181
Name:MACK, EVELYN GIL (CTRS)
Entity type:Individual
Prefix:MRS
First Name:EVELYN
Middle Name:GIL
Last Name:MACK
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4124 IMPERIAL EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33594-3965
Mailing Address - Country:US
Mailing Address - Phone:813-661-4358
Mailing Address - Fax:
Practice Address - Street 1:13000 BRUCE B DOWNS BLVD
Practice Address - Street 2:RT117
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4745
Practice Address - Country:US
Practice Address - Phone:813-972-2000
Practice Address - Fax:813-978-5852
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
39257OtherNATIONAL CERTIFICATION