Healthcare Provider Details

I. General information

NPI: 1215784293
Provider Name (Legal Business Name): EVOLVE DIAGNOSTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2024
Last Update Date: 05/06/2024
Certification Date: 05/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 E UNIVERSITY DR STE 3
MESA AZ
85203-8055
US

IV. Provider business mailing address

1010 E UNIVERSITY DR STE 3
MESA AZ
85203-8055
US

V. Phone/Fax

Practice location:
  • Phone: 480-550-6657
  • Fax: 928-365-9866
Mailing address:
  • Phone: 480-550-6657
  • Fax: 928-365-9866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MIA DROUIN
Title or Position: OWNER
Credential: BCB A
Phone: 480-550-6657