Provider Demographics
NPI:1811251838
Name:EVANGELISTA, SUSAN
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 DEHAVEN DR
Mailing Address - Street 2:APT 2D
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10703-1242
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24 DEHAVEN DR
Practice Address - Street 2:APT 2D
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10703-1242
Practice Address - Country:US
Practice Address - Phone:914-879-0276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-25
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst