Basic Information
| Provider Information | |||||||||
| NPI: | 1518926302 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EVANS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1430 BROADWAY RM 304 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100189226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128408410 | ||||||||
| FaxNumber: | 2128408415 | ||||||||
| Practice Location | |||||||||
| Address1: | 1430 BROADWAY RM 304 | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100189226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128408410 | ||||||||
| FaxNumber: | 2128408415 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 07/22/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | 014660 | NY | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
ID Information
| ID | Type | State | Issuer | Description | 02228926 | 05 | NY | MEDICAID |