MEDICARE: EVOLVE RESIDENTIAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	324500000X	Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1043957137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVE RESIDENTIAL LLC

Provider Business Mailing Address
First Line	:	2528 MOUNTAIN RD STE 204
Second Line	:
City	:	PASADENA
State	:	MD
Zip	:	21122-7204
Country	:	US
Telephone Number	:	443-548-3733
Fax Number	:

Provider Business Practice Location Address
First Line	:	6305 CAROLINA AVE
Second Line	:
City	:	GLEN BURNIE
State	:	MD
Zip	:	21061-1601
Country	:	US
Telephone Number	:	443-548-3733
Fax Number	:

Authorized Official
Title or Position	:	LICENSING & CREDENTIALING SPECIALIS
Name	:	JESSIE COSTLEY
Credential	:
Telephone Number	:	443-548-3733

Provider Enumeration Date	:	05/19/2022
Last Update Date	:	07/13/2025

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Directions to “EVOLVE RESIDENTIAL LLC ” Practice Location

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