MEDICARE: THE EVOLVING CHAIR COUNSELING AND CONSULTING AGENCY

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	251S00000X	Community/Behavioral Health Agency	6098-125	WI
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center	6098-125	WI
3	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	6098-125	WI

General Provider Information

NPI Number	:	1194233718
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE EVOLVING CHAIR COUNSELING AND CONSULTING AGENCY

Provider Business Mailing Address
First Line	:	7425 W FLORIST AVE
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53218-1850
Country	:	US
Telephone Number	:	414-748-1614
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 N 78TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53222-3916
Country	:	US
Telephone Number	:	414-395-0037
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT/CHILD & FAMILY THERAPIST
Name	:	MS. LAKIESHA RUSSELL
Credential	:	LPC
Telephone Number	:	414-395-0037

Provider Enumeration Date	:	01/17/2018
Last Update Date	:	01/17/2018

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