MEDICARE: EVOLVING MIND SOLUTIONS, 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	261QM0855X	Adolescent and Children Mental Health Clinic/Center
2	261QM0850X	Adult Mental Health Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1225577471	OTHER		TYPE 1 NPI

General Provider Information

NPI Number	:	1326681354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVING MIND SOLUTIONS, LLC

Provider Business Mailing Address
First Line	:	4200 S HULEN ST STE 678
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-7902
Country	:	US
Telephone Number	:	817-203-4779
Fax Number	:

Provider Business Practice Location Address
First Line	:	4200 S HULEN ST STE 678
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-7902
Country	:	US
Telephone Number	:	817-203-4779
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MRS. SARAH RYAN WELLBORN
Credential	:	LCSW
Telephone Number	:	817-203-4779

Provider Enumeration Date	:	10/22/2019
Last Update Date	:	10/09/2024

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