Provider Demographics
NPI:1538608567
Name:EVELYN, FERNELLA BROWN (CBHT)
Entity type:Individual
Prefix:MISS
First Name:FERNELLA
Middle Name:BROWN
Last Name:EVELYN
Suffix:
Gender:F
Credentials:CBHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:817 N DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33060-5621
Mailing Address - Country:US
Mailing Address - Phone:954-785-8285
Mailing Address - Fax:954-928-0004
Practice Address - Street 1:817 N DIXIE HWY
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33060-5621
Practice Address - Country:US
Practice Address - Phone:954-785-8285
Practice Address - Fax:954-928-0004
Is Sole Proprietor?:No
Enumeration Date:2017-02-23
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL100017106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL100017OtherCBHT