Provider Demographics
NPI:1194230086
Name:EVOLVE FAMILY THERAPY PC
Entity Type:Organization
Organization Name:EVOLVE FAMILY THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICIAN/COE
Authorized Official - Prefix:
Authorized Official - First Name:JONI
Authorized Official - Middle Name:LEA
Authorized Official - Last Name:DICKSON GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT #102382
Authorized Official - Phone:209-603-2929
Mailing Address - Street 1:3021 BALBOA DR
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-1905
Mailing Address - Country:US
Mailing Address - Phone:209-603-2929
Mailing Address - Fax:
Practice Address - Street 1:359 W 11TH ST STE A1
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3863
Practice Address - Country:US
Practice Address - Phone:209-603-2929
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102382261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)