Healthcare Provider Details

I. General information

NPI: 1386260289
Provider Name (Legal Business Name): EVOLVE WELLNESS CENTRE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2020
Last Update Date: 06/17/2020
Certification Date: 06/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9080 GREENWELL ST
BATON ROUGE LA
70812-2519
US

IV. Provider business mailing address

9080 GREENWELL ST
BATON ROUGE LA
70812-2519
US

V. Phone/Fax

Practice location:
  • Phone: 225-206-4060
  • Fax: 225-372-8649
Mailing address:
  • Phone: 225-206-4060
  • Fax: 225-372-8649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: DR. SHALANDA JUDGE
Title or Position: OWNER
Credential: EDD
Phone: 225-206-4060