=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457085904
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVOLUTION THERAPEUTIC SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2022
-----------------------------------------------------
Last Update Date | 07/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15401 WYLIE RD
-----------------------------------------------------
City | BRANDYWINE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20613-6216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-374-0609
-----------------------------------------------------
Fax | 301-808-6562
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15401 WYLIE RD
-----------------------------------------------------
City | BRANDYWINE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20613-6216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-374-0609
-----------------------------------------------------
Fax | 301-808-6562
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | STACEY VALERIE FERGUSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 240-899-3473
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------