Provider Demographics
NPI:1245895754
Name:MIND EVOLUTION
Entity type:Organization
Organization Name:MIND EVOLUTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RACHELE
Authorized Official - Middle Name:
Authorized Official - Last Name:KLASSY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:608-206-3767
Mailing Address - Street 1:1078 HWY 69
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-1487
Practice Address - Country:US
Practice Address - Phone:608-256-5115
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-09
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty