Provider Demographics
NPI:1518926302
Name:EVANS, MARK JOSEPH (PHD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:JOSEPH
Last Name:EVANS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 BROADWAY RM 304
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10018-9226
Mailing Address - Country:US
Mailing Address - Phone:212-840-8410
Mailing Address - Fax:212-840-8415
Practice Address - Street 1:1430 BROADWAY RM 304
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10018-9226
Practice Address - Country:US
Practice Address - Phone:212-840-8410
Practice Address - Fax:212-840-8415
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014660103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02228926Medicaid
NY02228926Medicaid
NYVL5021Medicare ID - Type Unspecified