MEDICARE: MR. EVAN A SEIDEL LCSW

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	1041C0700X	Clinical Social Worker	074263	NY

General Provider Information

NPI Number	:	1053644799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EVAN A SEIDEL LCSW

Provider Business Mailing Address
First Line	:	1 ASH CT
Second Line	:
City	:	NEW CITY
State	:	NY
Zip	:	10956-3746
Country	:	US
Telephone Number	:	516-721-0007
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 ASH CT
Second Line	:
City	:	NEW CITY
State	:	NY
Zip	:	10956-3746
Country	:	US
Telephone Number	:	845-548-8597
Fax Number	:

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

Provider Enumeration Date	:	09/14/2009
Last Update Date	:	12/31/2020

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