Provider Demographics
NPI:1174245732
Name:VIDA, EVAN VINCENT (PSYD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:VINCENT
Last Name:VIDA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 LOCUST ST APT 3708
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-4325
Mailing Address - Country:US
Mailing Address - Phone:203-803-6912
Mailing Address - Fax:
Practice Address - Street 1:1518 WALNUT ST STE 1702
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3409
Practice Address - Country:US
Practice Address - Phone:856-249-0757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-12
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X, 103TB0200X
PAPS020328103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103T00000XBehavioral Health & Social Service ProvidersPsychologist