Provider Demographics
NPI:1508315920
Name:EVOLVE THERAPEUTIC CENTER
Entity Type:Organization
Organization Name:EVOLVE THERAPEUTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:DECRAENE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-685-7601
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:MINOOKA
Mailing Address - State:IL
Mailing Address - Zip Code:60447-0608
Mailing Address - Country:US
Mailing Address - Phone:815-685-7601
Mailing Address - Fax:
Practice Address - Street 1:304 W MONDAMIN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:MINOOKA
Practice Address - State:IL
Practice Address - Zip Code:60447-9096
Practice Address - Country:US
Practice Address - Phone:815-685-7601
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-27
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008724101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty