=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053132357
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVOLVE THERAPY SOLUTIONS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2024
-----------------------------------------------------
Last Update Date | 10/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 53 LOGANBERRY CIR
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31602-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-560-6600
-----------------------------------------------------
Fax | 229-231-2980
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 53 LOGANBERRY CIR
-----------------------------------------------------
City | VALDOSTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31602-2303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 229-560-6600
-----------------------------------------------------
Fax | 229-231-2980
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SPEECH LANGUAGE PATHOLOGIST
-----------------------------------------------------
Name | VICTORIA ROSE LOVETT HERRING
-----------------------------------------------------
Credential | M.ED., CCC-SLP
-----------------------------------------------------
Telephone | 229-560-6600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------