Provider Demographics
NPI:1629806757
Name:EVANGELISTA, LAURA (MA)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:EVANGELISTA
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 326
Mailing Address - Street 2:
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084-0326
Mailing Address - Country:US
Mailing Address - Phone:860-716-6413
Mailing Address - Fax:
Practice Address - Street 1:1599 UPPER MAPLE ST
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-1554
Practice Address - Country:US
Practice Address - Phone:860-779-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional