=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831713536
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THOUGHT EVOLUTION LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2020
-----------------------------------------------------
Last Update Date | 05/29/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 847 N MILTON AVE
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21205-1613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-945-8581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 PARK AVE APT 410
-----------------------------------------------------
City | BALTIMORE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21201-5608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-945-8581
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AO
-----------------------------------------------------
Name | JOHN MARVIN BROWN
-----------------------------------------------------
Credential | LCADC
-----------------------------------------------------
Telephone | 443-945-8581
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------