=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639708563
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVOLVE COUNSELING CENTERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2020
-----------------------------------------------------
Last Update Date | 04/03/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1041 N WESTERN AVE
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60622-3571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-526-8650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4601 N MONTICELLO AVE APT 1
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60625-6401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-526-8650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PSYCHOTHERAPIST
-----------------------------------------------------
Name | ALISHA R WARREN
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 773-526-8650
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------