Provider Demographics
NPI:1538935309
Name:EVOLVE PEDIATRIC THERAPY LLC
Entity type:Organization
Organization Name:EVOLVE PEDIATRIC THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/SLP
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAUCK
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:304-268-7353
Mailing Address - Street 1:164 RAWHIDE LN
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH JUNCTION
Mailing Address - State:WV
Mailing Address - Zip Code:25442-4817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:164 RAWHIDE LN
Practice Address - Street 2:
Practice Address - City:SHENANDOAH JUNCTION
Practice Address - State:WV
Practice Address - Zip Code:25442-4817
Practice Address - Country:US
Practice Address - Phone:304-582-5320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-01
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty