Healthcare Provider Details

I. General information

NPI: 1912597857
Provider Name (Legal Business Name): EVOLVE MENTAL WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 WESLEY DR
SALISBURY MD
21801-7149
US

IV. Provider business mailing address

1411 WESLEY DR
SALISBURY MD
21801-7149
US

V. Phone/Fax

Practice location:
  • Phone: 410-642-4011
  • Fax:
Mailing address:
  • Phone: 410-642-4011
  • Fax: 410-630-1654

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 Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: VALERIE ANDERSON
Title or Position: OWNER
Credential: LCSWC
Phone: 410-642-4011