Provider Demographics
NPI:1235977968
Name:EVANS, WENDELL MARGO MAURICE (LCSW-R)
Entity type:Individual
Prefix:
First Name:WENDELL
Middle Name:MARGO MAURICE
Last Name:EVANS
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 OVERLOOK AVE APT 12A
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-7804
Mailing Address - Country:US
Mailing Address - Phone:347-213-8321
Mailing Address - Fax:
Practice Address - Street 1:555 ROCKAWAY PKWY # 113
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-3132
Practice Address - Country:US
Practice Address - Phone:718-240-5121
Practice Address - Fax:718-240-5121
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYRO41606-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical