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General NPI Number Information
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NPI Number | 1194263103
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Entity Type | Organization
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Legal Business Name | IEVOLVE TRANSFORMATIONAL SERVICES
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Dates
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Enumeration Date | 02/09/2017
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Last Update Date | 02/09/2017
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Provider Practice Location Address
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Address Line | 520 S GRAND AVE SUITE 680
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City | LOS ANGELES
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State | CA
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Zip | 90071-2600
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Country | US
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Telephone | 800-967-9416
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Fax | 800-967-9416
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Provider Business Mailing Address
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Address Line | 520 S GRAND AVE SUITE 680
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City | LOS ANGELES
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State | CA
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Zip | 90071-2600
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Country | US
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Telephone | 800-967-9416
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Fax | 800-967-9416
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Authorized Official
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Title or Position | CEO / LEAD CLINICIAN
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Name | MRS. KONGIT FARRELL
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Credential | M.A., L.M.F.T
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Telephone | 800-967-9416
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 97773
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License Number State | CA
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