Provider Demographics
NPI:1740916105
Name:EVOLVE BRAIN HEALTH LLC
Entity type:Organization
Organization Name:EVOLVE BRAIN HEALTH LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:KNIGHTLY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:978-857-1424
Mailing Address - Street 1:1055 SUMMER ST STE 2
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5527
Mailing Address - Country:US
Mailing Address - Phone:203-504-9758
Mailing Address - Fax:203-547-4914
Practice Address - Street 1:1055 SUMMER ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5527
Practice Address - Country:US
Practice Address - Phone:203-504-9758
Practice Address - Fax:203-504-9758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-28
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)