Provider Demographics
NPI:1043075302
Name:EVOLO PLLC
Entity Type:Organization
Organization Name:EVOLO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/FOUNDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:E
Authorized Official - Last Name:CANNELL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:208-727-7360
Mailing Address - Street 1:361 CRANBROOK RD
Mailing Address - Street 2:
Mailing Address - City:HAILEY
Mailing Address - State:ID
Mailing Address - Zip Code:83333-8817
Mailing Address - Country:US
Mailing Address - Phone:208-727-7360
Mailing Address - Fax:
Practice Address - Street 1:416 S MAIN ST STE 102
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8422
Practice Address - Country:US
Practice Address - Phone:208-727-7360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-15
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Single Specialty