Provider Demographics
NPI:1043957137
Name:EVOLVE RESIDENTIAL LLC
Entity type:Organization
Organization Name:EVOLVE RESIDENTIAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:JESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-548-3733
Mailing Address - Street 1:2528 MOUNTAIN RD STE 204
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-7204
Mailing Address - Country:US
Mailing Address - Phone:443-548-3733
Mailing Address - Fax:
Practice Address - Street 1:6305 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-1601
Practice Address - Country:US
Practice Address - Phone:443-548-3733
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVOLVE RESIDENTIAL LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-05-19
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility