Basic Information
| Provider Information | |||||||||
| NPI: | 1447469804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVERS | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 640 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE RAPIDS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278700640 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525365440 | ||||||||
| FaxNumber: | 2525365444 | ||||||||
| Practice Location | |||||||||
| Address1: | 2064 NC HIGHWAY 125 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE RAPIDS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278709436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525365000 | ||||||||
| FaxNumber: | 2525362258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 02/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TB0200X | 1410 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Cognitive & Behavioral | 103TC2200X | 1410 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent | 103TH0004X | 1410 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Health | 103TM1800X | 1410 | NC | N | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities | 103TC0700X | 1410 | NC | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 0345A | 01 | NC | NC BCBS | OTHER |