Provider Demographics
NPI:1013579093
Name:EVOLVE THERAPUETIC HEALTH AND WELLNESS SERVICES
Entity Type:Organization
Organization Name:EVOLVE THERAPUETIC HEALTH AND WELLNESS SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAMILTON
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:301-996-1677
Mailing Address - Street 1:16208 PENTERRA WAY
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716-1919
Mailing Address - Country:US
Mailing Address - Phone:301-996-1677
Mailing Address - Fax:
Practice Address - Street 1:16208 PENTERRA WAY
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716-1919
Practice Address - Country:US
Practice Address - Phone:301-996-1677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-01
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4515124Medicaid