MEDICARE: EVOLUTION HEALTHCARE MARRIAGE AND FAMILY THERAPY, INC.

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	106H00000X	Marriage & Family Therapist
3	101YM0800X	Mental Health Counselor
4	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1538014386
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLUTION HEALTHCARE MARRIAGE AND FAMILY THERAPY, INC.

Provider Business Mailing Address
First Line	:	101 S KRAEMER BLVD STE 220
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-6110
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	101 S KRAEMER BLVD STE 220
Second Line	:
City	:	PLACENTIA
State	:	CA
Zip	:	92870-6110
Country	:	US
Telephone Number	:	909-257-8287
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MICHAEL GALLESE
Credential	:
Telephone Number	:	949-257-2249

Provider Enumeration Date	:	02/26/2026
Last Update Date	:	03/13/2026

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