Provider Demographics
NPI:1316695018
Name:EVAN MICHAELS LCSW PC
Entity type:Organization
Organization Name:EVAN MICHAELS LCSW PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MICHAELS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:917-576-0720
Mailing Address - Street 1:2116 MERRICK AVE STE 2001
Mailing Address - Street 2:
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-3409
Mailing Address - Country:US
Mailing Address - Phone:917-576-0720
Mailing Address - Fax:
Practice Address - Street 1:2116 MERRICK AVE STE 2001
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3409
Practice Address - Country:US
Practice Address - Phone:917-576-0720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-13
Last Update Date:2022-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02454837Medicaid