Provider Demographics
NPI:1013588862
Name:EVOLVENCHANGE, LLC
Entity Type:Organization
Organization Name:EVOLVENCHANGE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIC MENTAL HEALTH NURSE PRA
Authorized Official - Prefix:
Authorized Official - First Name:LETISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGANS
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:609-422-0923
Mailing Address - Street 1:1451 CHEWS LANDING RD STE 207
Mailing Address - Street 2:
Mailing Address - City:LAUREL SPRINGS
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-2766
Mailing Address - Country:US
Mailing Address - Phone:856-341-2208
Mailing Address - Fax:
Practice Address - Street 1:1451 CHEWS LANDING RD STE 207
Practice Address - Street 2:
Practice Address - City:LAUREL SPRINGS
Practice Address - State:NJ
Practice Address - Zip Code:08021-2766
Practice Address - Country:US
Practice Address - Phone:856-341-2208
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-02
Last Update Date:2021-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)