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General NPI Number Information
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NPI Number | 1255120978
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Entity Type | Organization
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Legal Business Name | EVOLUTION OF SELF
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Dates
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Enumeration Date | 05/01/2025
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Last Update Date | 11/19/2025
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Provider Practice Location Address
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Address Line | 701 GREEN VALLEY RD STE 100 ROOM 330
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City | GREENSBORO
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State | NC
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Zip | 27408-7096
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Country | US
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Telephone | 336-618-7697
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Fax |
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Provider Business Mailing Address
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Address Line | 701 GREEN VALLEY RD STE 100 #330
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City | GREENSBORO
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State | NC
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Zip | 27408-7096
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DOMINIQUE SHAMBERGER
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Credential |
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Telephone | 336-618-7697
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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