=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538014386
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVOLUTION HEALTHCARE MARRIAGE AND FAMILY THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2026
-----------------------------------------------------
Last Update Date | 02/26/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 S KRAEMER BLVD STE 220
-----------------------------------------------------
City | PLACENTIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92870-6110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-257-8287
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 101 S KRAEMER BLVD STE 220
-----------------------------------------------------
City | PLACENTIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92870-6110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MICHAEL GALLESE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-257-8287
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------