Provider Demographics
NPI:1457085904
Name:EVOLUTION THERAPEUTIC SERVICES
Entity Type:Organization
Organization Name:EVOLUTION THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:VALERIE
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:240-899-3473
Mailing Address - Street 1:15401 WYLIE RD
Mailing Address - Street 2:
Mailing Address - City:BRANDYWINE
Mailing Address - State:MD
Mailing Address - Zip Code:20613-6216
Mailing Address - Country:US
Mailing Address - Phone:202-374-0609
Mailing Address - Fax:301-808-6562
Practice Address - Street 1:15401 WYLIE RD
Practice Address - Street 2:
Practice Address - City:BRANDYWINE
Practice Address - State:MD
Practice Address - Zip Code:20613-6216
Practice Address - Country:US
Practice Address - Phone:202-374-0609
Practice Address - Fax:301-808-6562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty