Healthcare Provider Details

I. General information

NPI: 1194233718
Provider Name (Legal Business Name): THE EVOLVING CHAIR COUNSELING AND CONSULTING AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2018
Last Update Date: 01/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 N 78TH ST
MILWAUKEE WI
53222-3916
US

IV. Provider business mailing address

7425 W FLORIST AVE
MILWAUKEE WI
53218-1850
US

V. Phone/Fax

Practice location:
  • Phone: 414-395-0037
  • Fax:
Mailing address:
  • Phone: 414-748-1614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number6098-125
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number6098-125
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6098-125
License Number StateWI

VIII. Authorized Official

Name: MS. LAKIESHA RUSSELL
Title or Position: PRESIDENT/CHILD & FAMILY THERAPIST
Credential: LPC
Phone: 414-395-0037