Provider Demographics
NPI:1962295873
Name:EVIDENTIAL THERAPY & WELLNESS LLC
Entity type:Organization
Organization Name:EVIDENTIAL THERAPY & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:IYOBOSA
Authorized Official - Middle Name:JOAN
Authorized Official - Last Name:OBASOGIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:667-303-2771
Mailing Address - Street 1:6 MALLOW CT
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-1300
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 MALLOW CT
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-1300
Practice Address - Country:US
Practice Address - Phone:443-491-9469
Practice Address - Fax:443-222-9310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-05-23
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty