Provider Demographics
NPI:1629594791
Name:PAGOULATOS, EVA (PSYD)
Entity Type:Individual
Prefix:
First Name:EVA
Middle Name:
Last Name:PAGOULATOS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13155 IXORA CT APT 305
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33181-2337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7300 W CAMINO REAL STE 204
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-5518
Practice Address - Country:US
Practice Address - Phone:561-368-8686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-20
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY8721103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical