Healthcare Provider Details

I. General information

NPI: 1568123966
Provider Name (Legal Business Name): EVOLVE LIFE CENTERS IOP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2022
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2528 MOUNTAIN RD STE 102-204
PASADENA MD
21122-7203
US

IV. Provider business mailing address

2528 MOUNTAIN RD STE 204
PASADENA MD
21122-7204
US

V. Phone/Fax

Practice location:
  • Phone: 443-548-3733
  • Fax: 410-360-1675
Mailing address:
  • Phone: 443-548-3733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: JESSIE COSTLEY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 443-548-3733