Healthcare Provider Details

I. General information

NPI: 1073187860
Provider Name (Legal Business Name): EVOLUTION COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/17/2021
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 4TH ST NE STE 1
DEVILS LAKE ND
58301-2542
US

IV. Provider business mailing address

1028 4TH ST NE
DEVILS LAKE ND
58301-2702
US

V. Phone/Fax

Practice location:
  • Phone: 701-665-3263
  • Fax:
Mailing address:
  • Phone: 701-665-3263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: SARA CHARLIE KELNER
Title or Position: COUNSELOR
Credential: LMAC LPCC
Phone: 701-665-3263