Provider Demographics
NPI:1306480470
Name:EVANS, STEPHANIE (MA)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:EVANS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 COMET LN
Mailing Address - Street 2:
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-7828
Mailing Address - Country:US
Mailing Address - Phone:516-459-1370
Mailing Address - Fax:
Practice Address - Street 1:300 GARDEN CITY PLZ STE 350
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:NY
Practice Address - Zip Code:11530-3358
Practice Address - Country:US
Practice Address - Phone:516-747-9030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-01
Last Update Date:2019-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY904597103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool