Provider Demographics
NPI:1518637719
Name:EVOLUTION OF A BLACK BUTTERFLY LLC
Entity Type:Organization
Organization Name:EVOLUTION OF A BLACK BUTTERFLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:FAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-218-8367
Mailing Address - Street 1:5960 S LAND PARK DR # 1108
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-3313
Mailing Address - Country:US
Mailing Address - Phone:916-426-6642
Mailing Address - Fax:
Practice Address - Street 1:7335 MEADOWGATE DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-2473
Practice Address - Country:US
Practice Address - Phone:916-218-8367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR1245580317OtherSUBSTANCE ABUSE