Provider Demographics
NPI:1699551226
Name:EVANGELISTA, VIRMANIA V
Entity type:Individual
Prefix:
First Name:VIRMANIA
Middle Name:V
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 1:1526 GRAND CONCOURSE FL 1
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-8400
Mailing Address - Country:US
Mailing Address - Phone:718-282-3425
Mailing Address - Fax:
Practice Address - Street 1:1526 GRAND CONCOURSE FL 1
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-8400
Practice Address - Country:US
Practice Address - Phone:718-282-3425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TA0400X
NY103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)