Healthcare Provider Details

I. General information

NPI: 1275369647
Provider Name (Legal Business Name): EVOLVE PSYCHIATRY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N51W34306 PARK BAY RD
OKAUCHEE WI
53069-9712
US

IV. Provider business mailing address

N51W34306 PARK BAY RD
OKAUCHEE WI
53069-9712
US

V. Phone/Fax

Practice location:
  • Phone: 414-531-2933
  • Fax:
Mailing address:
  • Phone: 414-531-2933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. ABBY JEAN BANECK
Title or Position: CEO, PROVIDER
Credential: FNP-BC, PMHNP-BC
Phone: 414-531-2933