Provider Demographics
NPI:1215092978
Name:EVANGELISTA, RICHARD JAMES (PHD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JAMES
Last Name:EVANGELISTA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 MUNROE AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT SINAI
Mailing Address - State:NY
Mailing Address - Zip Code:11766-1935
Mailing Address - Country:US
Mailing Address - Phone:631-807-7144
Mailing Address - Fax:
Practice Address - Street 1:144 LAKE AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-4219
Practice Address - Country:US
Practice Address - Phone:631-807-7144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008167-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical