Healthcare Provider Details

I. General information

NPI: 1215851019
Provider Name (Legal Business Name): MOON RIVER EVOLUTION, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 RIDGEWAY DR
BIRMINGHAM AL
35209-5506
US

IV. Provider business mailing address

212 W TROY ST STE B
DOTHAN AL
36303-4455
US

V. Phone/Fax

Practice location:
  • Phone: 205-410-5610
  • Fax:
Mailing address:
  • Phone: 205-410-5610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: PATTY CUSICK
Title or Position: MENTAL HEALTH COUNSELOR
Credential: M.ED, LPC
Phone: 205-410-5610