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General NPI Number Information
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NPI Number | 1679019608
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Entity Type | Organization
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Legal Business Name | EVOLUTION PSYCHOLOGICAL SERVICES, PC
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Dates
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Enumeration Date | 01/14/2017
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Last Update Date | 01/14/2017
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Provider Practice Location Address
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Address Line | 13885 HEDGEWOOD DR SUITE 349
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City | WOODBRIDGE
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State | VA
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Zip | 22193-7928
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Country | US
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Telephone | 703-317-7271
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Fax |
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Provider Business Mailing Address
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Address Line | 2465 DONNINGTON CT
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City | JEFFERSONTON
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State | VA
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Zip | 22724-1730
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Country | US
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Telephone | 540-937-7676
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | REGINALD HENRY MCRAE
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Credential | PSYD
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Telephone | 703-317-7271
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 0810004799
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License Number State | VA
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