Provider Demographics
NPI:1205314879
Name:WELLNESS EVOLUTION LLC
Entity type:Organization
Organization Name:WELLNESS EVOLUTION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:VILAS
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:RISSER
Authorized Official - Suffix:
Authorized Official - Credentials:LPCC, NCC
Authorized Official - Phone:575-644-3299
Mailing Address - Street 1:1225 MONTE VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-5629
Mailing Address - Country:US
Mailing Address - Phone:575-644-3299
Mailing Address - Fax:
Practice Address - Street 1:1225 MONTE VISTA AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-5629
Practice Address - Country:US
Practice Address - Phone:575-644-3299
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-05
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty