Provider Demographics
NPI:1376287276
Name:EVOLUTION BEHAVIORAL HEALTH SERVICES, LLC
Entity Type:Organization
Organization Name:EVOLUTION BEHAVIORAL HEALTH SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARCELO
Authorized Official - Middle Name:
Authorized Official - Last Name:LORENZO-LUACES PICO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-345-8357
Mailing Address - Street 1:23257 SOUTHDOWN MANOR TER UNIT 101
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20148-8176
Mailing Address - Country:US
Mailing Address - Phone:571-345-8357
Mailing Address - Fax:
Practice Address - Street 1:23257 SOUTHDOWN MANOR TER UNIT 101
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20148-8176
Practice Address - Country:US
Practice Address - Phone:571-345-8357
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty