Provider Demographics
NPI:1770659633
Name:EVANIER, VAUGHAN DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:VAUGHAN
Middle Name:DIANE
Last Name:EVANIER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 ALBEMARLE RD
Mailing Address - Street 2:2B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11218-2351
Mailing Address - Country:US
Mailing Address - Phone:718-522-4534
Mailing Address - Fax:
Practice Address - Street 1:415 ALBEMARLE RD
Practice Address - Street 2:2B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-2351
Practice Address - Country:US
Practice Address - Phone:718-522-4534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP0654161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1770659633Medicare NSC