Provider Demographics
NPI:1891437125
Name:EVOLVE THERAPEUTIC SERVICES, LLC
Entity Type:Organization
Organization Name:EVOLVE THERAPEUTIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIDAH
Authorized Official - Middle Name:
Authorized Official - Last Name:OTIENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-468-2232
Mailing Address - Street 1:2307 W CONE BLVD STE 140
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-4063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2307 W CONE BLVD STE 140
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-4063
Practice Address - Country:US
Practice Address - Phone:336-772-4158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health