=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972129591
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVOLVED COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2020
-----------------------------------------------------
Last Update Date | 06/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8814 TALON RIDGE DR
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40229-6648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-689-9952
-----------------------------------------------------
Fax | 502-632-1432
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8814 TALON RIDGE DR
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40229-6648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-689-9952
-----------------------------------------------------
Fax | 502-632-1432
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING ADMINISTRATOR
-----------------------------------------------------
Name | MRS. JACQUELINE SANDERS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-630-2036
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------