MEDICARE: EVOLVIA NEURO-BEHAVIORAL HEALTH 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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1447120530
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVIA NEURO-BEHAVIORAL HEALTH LLC

Provider Business Mailing Address
First Line	:	109 BISHOP RD
Second Line	:
City	:	CROCKETT
State	:	CA
Zip	:	94525-1515
Country	:	US
Telephone Number	:	623-703-8236
Fax Number	:

Provider Business Practice Location Address
First Line	:	1126 W HELENA DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85023-2626
Country	:	US
Telephone Number	:	602-921-4143
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	PAULSEN MYLES
Credential	:
Telephone Number	:	623-703-8236

Provider Enumeration Date	:	11/05/2025
Last Update Date	:	11/05/2025

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