MEDICARE: EVOLVING PERSPECTIVE MENTAL HEALTH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist

General Provider Information

NPI Number	:	1063180925
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVING PERSPECTIVE MENTAL HEALTH

Provider Business Mailing Address
First Line	:	1721 LILAC LN
Second Line	:
City	:	NORTH MANKATO
State	:	MN
Zip	:	56003-1428
Country	:	US
Telephone Number	:	507-320-9060
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 WARREN ST
Second Line	:
City	:	MANKATO
State	:	MN
Zip	:	56001-3762
Country	:	US
Telephone Number	:	507-320-9060
Fax Number	:

Authorized Official
Title or Position	:	THERAPIST
Name	:	ANN THOMPSON
Credential	:	LMFT
Telephone Number	:	507-469-4458

Provider Enumeration Date	:	09/03/2021
Last Update Date	:	09/03/2021

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