Provider Demographics
NPI:1700681475
Name:EVOLVE THERAPY PRACTICE
Entity type:Organization
Organization Name:EVOLVE THERAPY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JEN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOLLUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:712-363-0917
Mailing Address - Street 1:3053 CENTER POINT RD NE STE B
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-4049
Mailing Address - Country:US
Mailing Address - Phone:319-777-9536
Mailing Address - Fax:
Practice Address - Street 1:3053 CENTER POINT RD NE STE B
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52402-4049
Practice Address - Country:US
Practice Address - Phone:319-777-9536
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty