=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720629462
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVOLUTION PSYCHOTHERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2019
-----------------------------------------------------
Last Update Date | 10/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 133 BLAKELY RD STE 202
-----------------------------------------------------
City | COLCHESTER
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05446-3984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-448-0448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 541
-----------------------------------------------------
City | COLCHESTER
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05446-0541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-448-0448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MICHAEL SHEPPARD
-----------------------------------------------------
Credential | LCMHC
-----------------------------------------------------
Telephone | 802-448-0448
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------