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Organization
EVOLUTION MIND, LLC
Active
Organization
EVOLUTION MIND, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KIRA BASKERVILLE-WILLIAMS MSW, LCSW, ED.S (CO-OWNER)
(973) 801-1801
Entity
Organization
Contact information
Practice address
2130 MILLBURN AVE STE D2, MAPLEWOOD, NJ 07040-3749
(973) 801-1801
(908) 964-0809
Mailing address
1286 MARCELLA DR, UNION, NJ 07083-6243
(973) 801-1801
Taxonomy
Speciality
Code
Description
License number
State
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1336699529
NPI
NJ
Enumeration date
06/29/2017
Last updated
10/23/2017
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