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General NPI Number Information
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NPI Number | 1568123966
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Entity Type | Organization
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Legal Business Name | EVOLVE LIFE CENTERS IOP LLC
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Dates
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Enumeration Date | 01/07/2022
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Last Update Date | 03/24/2023
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Provider Practice Location Address
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Address Line | 2528 MOUNTAIN RD STE 102-204
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City | PASADENA
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State | MD
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Zip | 21122-7203
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Country | US
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Telephone | 443-548-3733
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Fax | 410-360-1675
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Provider Business Mailing Address
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Address Line | 2528 MOUNTAIN RD STE 204
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City | PASADENA
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State | MD
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Zip | 21122-7204
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Country | US
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Telephone | 443-548-3733
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | JESSIE COSTLEY
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Credential |
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Telephone | 443-548-3733
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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