MEDICARE: DR. RICHARD JAMES EVANGELISTA PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	008167-1	NY

General Provider Information

NPI Number	:	1215092978
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD JAMES EVANGELISTA PH.D.

Provider Business Mailing Address
First Line	:	11 MUNROE AVE
Second Line	:
City	:	MOUNT SINAI
State	:	NY
Zip	:	11766-1935
Country	:	US
Telephone Number	:	631-807-7144
Fax Number	:

Provider Business Practice Location Address
First Line	:	144 LAKE AVE
Second Line	:
City	:	DEER PARK
State	:	NY
Zip	:	11729-4219
Country	:	US
Telephone Number	:	631-807-7144
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2006
Last Update Date	:	07/08/2007

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