Provider Demographics
NPI:1003052119
Name:EVOLVE CARE
Entity Type:Organization
Organization Name:EVOLVE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JANNET
Authorized Official - Middle Name:TISDALE
Authorized Official - Last Name:BLUE
Authorized Official - Suffix:
Authorized Official - Credentials:QMHP
Authorized Official - Phone:336-926-6463
Mailing Address - Street 1:897 PETERS CREEK PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3858
Mailing Address - Country:US
Mailing Address - Phone:336-725-9135
Mailing Address - Fax:336-725-9139
Practice Address - Street 1:897 PETERS CREEK PKWY STE 101
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3858
Practice Address - Country:US
Practice Address - Phone:336-725-9135
Practice Address - Fax:336-725-9139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-18
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health