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General NPI Number Information
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NPI Number | 1215092978
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Entity Type | Individual
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Provider Name | RICHARD JAMES EVANGELISTA PH.D.
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Gender | Male
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Dates
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Enumeration Date | 12/23/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 144 LAKE AVE
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City | DEER PARK
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State | NY
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Zip | 11729-4219
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Country | US
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Telephone | 631-807-7144
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Fax |
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Provider Business Mailing Address
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Address Line | 11 MUNROE AVE
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City | MOUNT SINAI
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State | NY
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Zip | 11766-1935
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Country | US
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Telephone | 631-807-7144
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 008167-1
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License Number State | NY
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