Provider Demographics
NPI:1245576248
Name:CHAN, EVANGELINA (MSW,LCSW)
Entity Type:Individual
Prefix:
First Name:EVANGELINA
Middle Name:
Last Name:CHAN
Suffix:
Gender:F
Credentials:MSW,LCSW
Other - Prefix:
Other - First Name:EVANGELINA
Other - Middle Name:
Other - Last Name:NG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSW,LCSW
Mailing Address - Street 1:4 W 125TH ST
Mailing Address - Street 2:FL 2
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-4575
Mailing Address - Country:US
Mailing Address - Phone:212-942-5615
Mailing Address - Fax:212-682-2613
Practice Address - Street 1:46 ALBION ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-2602
Practice Address - Country:US
Practice Address - Phone:203-330-6000
Practice Address - Fax:203-330-6008
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY081696-12084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008301OtherLICENSE
CT004236148Medicaid