=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992050512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EVAN SKOLNIK PSY.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2012
-----------------------------------------------------
Last Update Date | 01/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 50 NEW YORK AVE STE 101
-----------------------------------------------------
City | SMITHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11787-3448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-652-3361
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 BROOKLYN BLVD
-----------------------------------------------------
City | BRIGHTWATERS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11718-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-352-2638
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 025569
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------