Provider Demographics
NPI:1043716236
Name:EVANGELISTO, CAROL ANNE
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ANNE
Last Name:EVANGELISTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HILTON CT
Mailing Address - Street 2:
Mailing Address - City:PENNINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08534-1959
Mailing Address - Country:US
Mailing Address - Phone:609-730-9422
Mailing Address - Fax:
Practice Address - Street 1:3 S MAIN ST
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08501-1683
Practice Address - Country:US
Practice Address - Phone:609-208-3053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-05
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00135300101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional