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General NPI Number Information
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NPI Number | 1144815135
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Entity Type | Organization
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Legal Business Name | THE MOM EVOLUTION
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Dates
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Enumeration Date | 03/02/2021
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Last Update Date | 03/02/2021
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Provider Practice Location Address
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Address Line | 45 NW GREELEY AVE
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City | BEND
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State | OR
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Zip | 97703-2943
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Country | US
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Telephone | 877-831-1535
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Fax |
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Provider Business Mailing Address
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Address Line | 45 NW GREELEY AVE
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City | BEND
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State | OR
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Zip | 97703-2943
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Country | US
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Telephone | 877-831-1535
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Fax |
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Authorized Official
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Title or Position | THERAPIST AND OWNER
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Name | MRS. ADELINE HOLTER
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Credential | LCSW, LAC
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Telephone | 877-831-1535
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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