Healthcare Provider Details

I. General information

NPI: 1720830995
Provider Name (Legal Business Name): EVOLVING TREE THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2024
Last Update Date: 04/02/2024
Certification Date: 04/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

95 MAIN ST STE 200
CANAAN CT
06018-2463
US

IV. Provider business mailing address

PO BOX 1123
CANAAN CT
06018-1123
US

V. Phone/Fax

Practice location:
  • Phone: 203-947-3764
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. SARAH DOROTHY OSBORNE
Title or Position: CEO
Credential: LPC, LADC
Phone: 203-947-3764