Provider Demographics
NPI:1417022658
Name:MICHAELS, EVAN M (LCSW)
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:M
Last Name:MICHAELS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 FRANKEL BLVD
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-4732
Mailing Address - Country:US
Mailing Address - Phone:917-576-0720
Mailing Address - Fax:
Practice Address - Street 1:31 MERRICK AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3477
Practice Address - Country:US
Practice Address - Phone:917-576-0720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR047298-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN5I811Medicare ID - Type UnspecifiedCLINICAL SOCIAL WORKER