Healthcare Provider Details

I. General information

NPI: 1780548834
Provider Name (Legal Business Name): EVOLUTION AND WELLNESS THERAPY GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BO. MAMEY, CARR. 4417 KM 0.1
AGUADA PR
00602
US

IV. Provider business mailing address

CALL BOX 40000 SUITE 113
AGUADA PR
00602
US

V. Phone/Fax

Practice location:
  • Phone: 787-624-9258
  • Fax:
Mailing address:
  • Phone: 787-624-9258
  • Fax:

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: MR. EDNIE J RUIZ CARRERO
Title or Position: PRESIDENTE
Credential: LCSW
Phone: 787-624-9258