Provider Demographics
NPI:1912428905
Name:EVOLUTION MIND, LLC
Entity Type:Organization
Organization Name:EVOLUTION MIND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:BASKERVILLE-WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, LCSW, EDS
Authorized Official - Phone:973-801-1801
Mailing Address - Street 1:1286 MARCELLA DR
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-6243
Mailing Address - Country:US
Mailing Address - Phone:973-801-1801
Mailing Address - Fax:
Practice Address - Street 1:2130 MILLBURN AVE STE D2
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07040-3749
Practice Address - Country:US
Practice Address - Phone:973-801-1801
Practice Address - Fax:908-964-0809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-29
Last Update Date:2017-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1336699529OtherNPI