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General NPI Number Information
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NPI Number | 1518637719
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Entity Type | Organization
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Legal Business Name | EVOLUTION OF A BLACK BUTTERFLY LLC
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Dates
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Enumeration Date | 09/17/2021
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Last Update Date | 09/17/2021
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Provider Practice Location Address
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Address Line | 7335 MEADOWGATE DR
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City | SACRAMENTO
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State | CA
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Zip | 95823-2473
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Country | US
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Telephone | 916-218-8367
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Fax |
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Provider Business Mailing Address
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Address Line | 5960 S LAND PARK DR # 1108
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City | SACRAMENTO
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State | CA
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Zip | 95822-3313
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Country | US
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Telephone | 916-426-6642
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | FAREN JOHNSON
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Credential |
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Telephone | 916-218-8367
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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