Provider Demographics
NPI:1578779724
Name:IMBER-BLACK, EVAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:IMBER-BLACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553-1210
Mailing Address - Country:US
Mailing Address - Phone:914-699-8404
Mailing Address - Fax:914-699-1548
Practice Address - Street 1:149 E 78TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-0405
Practice Address - Country:US
Practice Address - Phone:212-879-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY527106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist