Provider Demographics
NPI:1730825514
Name:EVOLVE MIND WELLNESS, INC
Entity type:Organization
Organization Name:EVOLVE MIND WELLNESS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, CFO, SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:GERMAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:ASCANI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-991-3831
Mailing Address - Street 1:1020 GRAVENSTEIN HWY S STE 120
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4863
Mailing Address - Country:US
Mailing Address - Phone:415-991-3831
Mailing Address - Fax:
Practice Address - Street 1:1020 GRAVENSTEIN HWY S STE 120
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4863
Practice Address - Country:US
Practice Address - Phone:415-991-3831
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty