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General NPI Number Information
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NPI Number | 1962295873
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Entity Type | Organization
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Legal Business Name | EVIDENTIAL THERAPY & WELLNESS LLC
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Dates
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Enumeration Date | 05/23/2025
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Last Update Date | 05/23/2025
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Provider Practice Location Address
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Address Line | 6 MALLOW CT
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City | NOTTINGHAM
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State | MD
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Zip | 21236-1300
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Country | US
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Telephone | 443-491-9469
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Fax | 443-222-9310
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Provider Business Mailing Address
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Address Line | 6 MALLOW CT
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City | NOTTINGHAM
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State | MD
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Zip | 21236-1300
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | IYOBOSA JOAN OBASOGIE
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Credential |
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Telephone | 667-303-2771
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number |
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License Number State |
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