Provider Demographics
NPI:1598260630
Name:PERSONAL EVOLUTION LLC
Entity Type:Organization
Organization Name:PERSONAL EVOLUTION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:
Authorized Official - Last Name:GLICK
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LCADC
Authorized Official - Phone:215-469-1155
Mailing Address - Street 1:2551 E LEHIGH AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-3831
Mailing Address - Country:US
Mailing Address - Phone:215-469-1155
Mailing Address - Fax:
Practice Address - Street 1:2551 E LEHIGH AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-3831
Practice Address - Country:US
Practice Address - Phone:215-469-1155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37LC00180700101YA0400X
NJ37PC00477600101YP2500X
PAPC009315101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty