MEDICARE: EVOLVE COUNSELING SERVICES 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	261QM0850X	Adult Mental Health Clinic/Center	LPC.0006480	CO

General Provider Information

NPI Number	:	1639667652
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVOLVE COUNSELING SERVICES LLC

Provider Business Mailing Address
First Line	:	2601 S LEMAY AVE
Second Line	:	STE. 7 #152
City	:	FORT COLLINS
State	:	CO
Zip	:	80525-2298
Country	:	US
Telephone Number	:	970-232-9339
Fax Number	:	970-232-9367

Provider Business Practice Location Address
First Line	:	1136 E. STUART
Second Line	:	BLDG. 4 STE. 101
City	:	FORT COLLINS
State	:	CO
Zip	:	80525
Country	:	US
Telephone Number	:	970-232-9339
Fax Number	:	970-232-9367

Authorized Official
Title or Position	:	OWNER
Name	:	LINDSEY LEE PHILLIPS
Credential	:	LPC
Telephone Number	:	719-440-5475

Provider Enumeration Date	:	04/25/2018
Last Update Date	:	04/25/2018

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