Provider Demographics
NPI:1548881584
Name:EVOLVE THERAPEUTIC SERVICES
Entity type:Organization
Organization Name:EVOLVE THERAPEUTIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:844-365-7676
Mailing Address - Street 1:PO BOX 433
Mailing Address - Street 2:
Mailing Address - City:ELMER
Mailing Address - State:NJ
Mailing Address - Zip Code:08318-0433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 S BROADWAY
Practice Address - Street 2:
Practice Address - City:PITMAN
Practice Address - State:NJ
Practice Address - Zip Code:08071-2235
Practice Address - Country:US
Practice Address - Phone:844-365-7676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-30
Last Update Date:2020-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty