=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639602261
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVOLUTIONS COUNSELING AND CONSULTING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2017
-----------------------------------------------------
Last Update Date | 04/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24441 EVERGREEN RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-5559
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-516-4533
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3725
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48037-3725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | ERICA KELLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-516-4533
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 6401009344
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------