MEDICARE: EVOLVE THERAPY CENTER 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	106H00000X	Marriage & Family Therapist
2	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1316462997
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVE THERAPY CENTER LLC

Provider Business Mailing Address
First Line	:	10290 S PROGRESS WAY STE 205
Second Line	:
City	:	PARKER
State	:	CO
Zip	:	80134-9056
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10290 S PROGRESS WAY STE 205
Second Line	:
City	:	PARKER
State	:	CO
Zip	:	80134-9056
Country	:	US
Telephone Number	:	720-573-0390
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DESIREE MCALLISTER
Credential	:
Telephone Number	:	720-573-0390

Provider Enumeration Date	:	08/04/2017
Last Update Date	:	10/31/2017

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