Provider Demographics
NPI:1275369647
Name:EVOLVE PSYCHIATRY AND WELLNESS
Entity type:Organization
Organization Name:EVOLVE PSYCHIATRY AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ABBY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BANECK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC, PMHNP-BC
Authorized Official - Phone:414-531-2933
Mailing Address - Street 1:N51W34306 PARK BAY RD
Mailing Address - Street 2:
Mailing Address - City:OKAUCHEE
Mailing Address - State:WI
Mailing Address - Zip Code:53069-9712
Mailing Address - Country:US
Mailing Address - Phone:414-531-2933
Mailing Address - Fax:
Practice Address - Street 1:N51W34306 PARK BAY RD
Practice Address - Street 2:
Practice Address - City:OKAUCHEE
Practice Address - State:WI
Practice Address - Zip Code:53069-9712
Practice Address - Country:US
Practice Address - Phone:414-531-2933
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-11
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty