Provider Demographics
NPI:1649478504
Name:EVANS, JUDITH (LP)
Entity type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:474 9TH ST
Mailing Address - Street 2:APT.#1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11215-4103
Mailing Address - Country:US
Mailing Address - Phone:718-499-2131
Mailing Address - Fax:
Practice Address - Street 1:915 BROADWAY
Practice Address - Street 2:1309
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-7108
Practice Address - Country:US
Practice Address - Phone:212-714-7126
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000106102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000106OtherLICENSE