Provider Demographics
NPI:1265502678
Name:EVANGELISTA, MARIA CELIA (PT)
Entity Type:Individual
Prefix:MISS
First Name:MARIA
Middle Name:CELIA
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:77 NEWARK AVE
Mailing Address - Street 2:SUITE A&B
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-4143
Mailing Address - Country:US
Mailing Address - Phone:973-759-1100
Mailing Address - Fax:973-759-1170
Practice Address - Street 1:4175 VETERAN MEMORIAL HWY
Practice Address - Street 2:SUITE 202
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7639
Practice Address - Country:US
Practice Address - Phone:631-580-5200
Practice Address - Fax:631-580-5222
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2009-11-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ40QA01192400225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ106059SRMMedicare PIN