Organization
EVOLVE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ELLIOTT RICHELSON (AUTHORIZED OFFICIAL)
(904) 514-7070
Entity
Organization
Contact information
Practice address
3416 ASSOCIATION DR, APPLETON, WI 54914
(920) 364-9078
(920) 243-1792
Mailing address
320 1ST ST STE 712, JAX BEACH, FL 32250
Taxonomy
Speciality
Code
Description
License number
State
101YP2500X
Professional Counselor
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
Primary
—
—
261QM0850X
Adult Mental Health Clinic/Center
—
—
261QM0855X
Adolescent and Children Mental Health Clinic/Center
—
—
323P00000X
Psychiatric Residential Treatment Facility
—
—
Other
Enumeration date
08/03/2016
Last updated
06/29/2023
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