Healthcare Provider Details

I. General information

NPI: 1730043423
Provider Name (Legal Business Name): EVOLUTION CLINICAL COUNSELING AND SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149C GREEN ST
GRENADA MS
38901-2618
US

IV. Provider business mailing address

751 CHOCTAW ST
GRENADA MS
38901-5317
US

V. Phone/Fax

Practice location:
  • Phone: 662-614-4441
  • Fax: 601-510-7558
Mailing address:
  • Phone: 662-614-4441
  • Fax: 601-510-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. ANGELA D. MILLER
Title or Position: CLINICIAN/OWNER
Credential: LCSW
Phone: 662-614-4441