Provider Demographics
NPI:1821690645
Name:EVERSLEY, CLARENCE
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:
Last Name:EVERSLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 ESSEX RD
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2022
Mailing Address - Country:US
Mailing Address - Phone:908-387-3288
Mailing Address - Fax:
Practice Address - Street 1:497 ROCKAWAY AVE
Practice Address - Street 2:
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1909
Practice Address - Country:US
Practice Address - Phone:718-845-2621
Practice Address - Fax:718-845-2622
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health