Provider Demographics
NPI:1992505408
Name:EVANGELISTA, BRADLEY MURRAY
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:MURRAY
Last Name:EVANGELISTA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 S HUMPHREY AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1712
Mailing Address - Country:US
Mailing Address - Phone:847-366-1227
Mailing Address - Fax:
Practice Address - Street 1:533 S HUMPHREY AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60304-1712
Practice Address - Country:US
Practice Address - Phone:847-366-1227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-14
Last Update Date:2025-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178021384101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional