Provider Demographics
NPI:1699808519
Name:EVANGELISTA, NANCY JO (PHD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:JO
Last Name:EVANGELISTA
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 1:10 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:ALFRED
Mailing Address - State:NY
Mailing Address - Zip Code:14802-1102
Mailing Address - Country:US
Mailing Address - Phone:607-968-0616
Mailing Address - Fax:607-587-9533
Practice Address - Street 1:10 CHURCH ST
Practice Address - Street 2:
Practice Address - City:ALFRED
Practice Address - State:NY
Practice Address - Zip Code:14802-1102
Practice Address - Country:US
Practice Address - Phone:607-968-0616
Practice Address - Fax:607-587-9533
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009840-1103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11514985OtherCAHQ UNIVERSAL CREDENTIAL