Provider Demographics
NPI:1679019608
Name:EVOLUTION PSYCHOLOGICAL SERVICES, PC
Entity Type:Organization
Organization Name:EVOLUTION PSYCHOLOGICAL SERVICES, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:REGINALD
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:MCRAE
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:703-317-7271
Mailing Address - Street 1:2465 DONNINGTON CT
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONTON
Mailing Address - State:VA
Mailing Address - Zip Code:22724-1730
Mailing Address - Country:US
Mailing Address - Phone:540-937-7676
Mailing Address - Fax:
Practice Address - Street 1:13885 HEDGEWOOD DR
Practice Address - Street 2:SUITE 349
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193-7928
Practice Address - Country:US
Practice Address - Phone:703-317-7271
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-14
Last Update Date:2017-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004799103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty