Healthcare Provider Details

I. General information

NPI: 1740916105
Provider Name (Legal Business Name): EVOLVE BRAIN HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2022
Last Update Date: 09/30/2024
Certification Date: 09/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 SUMMER ST
STAMFORD CT
06905-5527
US

IV. Provider business mailing address

1055 SUMMER ST STE 2
STAMFORD CT
06905-5527
US

V. Phone/Fax

Practice location:
  • Phone: 203-504-9758
  • Fax: 203-504-9758
Mailing address:
  • Phone: 203-504-9758
  • Fax: 203-547-4914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. THOMAS JOSEPH KNIGHTLY JR.
Title or Position: OWNER
Credential: MD
Phone: 978-857-1424