Provider Demographics
NPI:1285828079
Name:SICALIDES, EVANGELINE IRENE (PHD)
Entity Type:Individual
Prefix:
First Name:EVANGELINE
Middle Name:IRENE
Last Name:SICALIDES
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:RENEE
Other - Middle Name:
Other - Last Name:SICALIDES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:345 7TH AVE
Mailing Address - Street 2:SUITE 1602
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10001-5006
Mailing Address - Country:US
Mailing Address - Phone:646-552-0939
Mailing Address - Fax:
Practice Address - Street 1:345 7TH AVE
Practice Address - Street 2:SUITE 1602
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-5006
Practice Address - Country:US
Practice Address - Phone:646-552-0939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015727-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
11518469OtherCAQH
NYVM9011Medicare PIN