Provider Demographics
NPI:1467787515
Name:EVANGELISTA, MANUEL NAZARENO (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MANUEL
Middle Name:NAZARENO
Last Name:EVANGELISTA
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 1:860 EAST 4500 SOUTH #302
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84107
Mailing Address - Country:US
Mailing Address - Phone:801-268-0333
Mailing Address - Fax:801-268-3777
Practice Address - Street 1:860 EAST 4500 SOUTH #302
Practice Address - Street 2:
Practice Address - City:SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84107
Practice Address - Country:US
Practice Address - Phone:801-268-0333
Practice Address - Fax:801-268-3777
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-07
Last Update Date:2009-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6417919-3501104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker