Provider Demographics
NPI:1205358512
Name:EVOLVE PSYCHOTHERAPY SERVICES LLC
Entity Type:Organization
Organization Name:EVOLVE PSYCHOTHERAPY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AGENT
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFOREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-633-4358
Mailing Address - Street 1:2030 PACKARD ST STE B
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4785
Mailing Address - Country:US
Mailing Address - Phone:708-663-6279
Mailing Address - Fax:734-648-0581
Practice Address - Street 1:2030 PACKARD ST STE B
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4785
Practice Address - Country:US
Practice Address - Phone:708-663-6279
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-10
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801093987261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)