Healthcare Provider Details

I. General information

NPI: 1003498973
Provider Name (Legal Business Name): EVOLVE PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 US 41 N STE B
HENDERSON KY
42420-2376
US

IV. Provider business mailing address

PO BOX 3276
EVANSVILLE IN
47731-3276
US

V. Phone/Fax

Practice location:
  • Phone: 812-228-6896
  • Fax:
Mailing address:
  • Phone: 812-473-0181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0200X
TaxonomyPediatric Occupational Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: KASIE A BALLARD
Title or Position: OWNER/OCCUPATIONAL THERAPIST
Credential: MS, OTR/L
Phone: 812-228-6896