Healthcare Provider Details

I. General information

NPI: 1164200614
Provider Name (Legal Business Name): EVOLVING LICENSED CLINICAL SOCIAL WORK, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2023
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 W WATER ST STE 256
ELMIRA NY
14901-2912
US

IV. Provider business mailing address

427 HERRICK ST
ELMIRA NY
14904-1614
US

V. Phone/Fax

Practice location:
  • Phone: 607-398-0631
  • Fax:
Mailing address:
  • Phone: 607-398-0631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
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: HOLLY J MCCORMICK
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSWR
Phone: 607-398-0631