Provider Demographics
NPI:1821541137
Name:EVOLVE LLC
Entity Type:Organization
Organization Name:EVOLVE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ELLIOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-514-7070
Mailing Address - Street 1:320 1ST ST STE 712
Mailing Address - Street 2:
Mailing Address - City:JAX BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3416 ASSOCIATION DR
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54914
Practice Address - Country:US
Practice Address - Phone:920-364-9078
Practice Address - Fax:920-243-1792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-03
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility