Provider Demographics
NPI:1932815644
Name:EVOLVE THERAPY AND WELLNESS PLLC
Entity Type:Organization
Organization Name:EVOLVE THERAPY AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SOURACHACK
Authorized Official - Middle Name:S
Authorized Official - Last Name:SANANIKONE
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:850-418-0014
Mailing Address - Street 1:2786 INVERNESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32563-3049
Mailing Address - Country:US
Mailing Address - Phone:850-418-0014
Mailing Address - Fax:
Practice Address - Street 1:209 S A ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32502-5554
Practice Address - Country:US
Practice Address - Phone:850-533-0266
Practice Address - Fax:850-807-5446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-25
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty