Provider Demographics
NPI:1679225825
Name:EVOLUTION PSYCHIATRY, LLC
Entity Type:Organization
Organization Name:EVOLUTION PSYCHIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNAN
Authorized Official - Middle Name:
Authorized Official - Last Name:VICTORINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:774-365-9192
Mailing Address - Street 1:3012 SAN CLARA DR # 18C
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33445-5429
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:915 MIDDLE RIVER DR STE 103C
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33304-3559
Practice Address - Country:US
Practice Address - Phone:774-365-9192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-19
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty