Provider Demographics
NPI:1972129591
Name:EVOLVED COUNSELING
Entity Type:Organization
Organization Name:EVOLVED COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-630-2036
Mailing Address - Street 1:8814 TALON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40229-6648
Mailing Address - Country:US
Mailing Address - Phone:502-689-9952
Mailing Address - Fax:502-632-1432
Practice Address - Street 1:8814 TALON RIDGE DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40229-6648
Practice Address - Country:US
Practice Address - Phone:502-689-9952
Practice Address - Fax:502-632-1432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100339200Medicaid