Provider Demographics
NPI:1568123966
Name:EVOLVE LIFE CENTERS IOP LLC
Entity Type:Organization
Organization Name:EVOLVE LIFE CENTERS IOP LLC
Other - Org Name:ELC MENTAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-548-3733
Mailing Address - Street 1:2528 MOUNTAIN RD STE 204
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-7204
Mailing Address - Country:US
Mailing Address - Phone:443-548-3733
Mailing Address - Fax:
Practice Address - Street 1:2528 MOUNTAIN RD STE 102-204
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:MD
Practice Address - Zip Code:21122-7203
Practice Address - Country:US
Practice Address - Phone:443-548-3733
Practice Address - Fax:410-360-1675
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVOLVE LIFE CENTERS IOP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-01-07
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD200468200Medicaid