Provider Demographics
NPI:1760912265
Name:EVANCHIK, TINA MARIE (BA)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:MARIE
Last Name:EVANCHIK
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 ROUTE 539
Mailing Address - Street 2:
Mailing Address - City:WHITING
Mailing Address - State:NJ
Mailing Address - Zip Code:08759-3336
Mailing Address - Country:US
Mailing Address - Phone:732-716-0700
Mailing Address - Fax:732-716-0934
Practice Address - Street 1:725 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-5968
Practice Address - Country:US
Practice Address - Phone:732-367-2665
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2017-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029807Medicaid