Provider Demographics
NPI:1831429240
Name:PODOLAK, EVAN R (PSYD)
Entity type:Individual
Prefix:DR
First Name:EVAN
Middle Name:R
Last Name:PODOLAK
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 FENIMORE DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-1413
Mailing Address - Country:US
Mailing Address - Phone:914-714-3108
Mailing Address - Fax:
Practice Address - Street 1:1600 HARRISON AVE
Practice Address - Street 2:SUITE 307B
Practice Address - City:MAMARONECK
Practice Address - State:NY
Practice Address - Zip Code:10543-3145
Practice Address - Country:US
Practice Address - Phone:914-835-3910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-06
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018395-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical