Provider Demographics
NPI:1104696467
Name:EVOLVINN THERAPY
Entity type:Organization
Organization Name:EVOLVINN THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DOS SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:703-520-7878
Mailing Address - Street 1:1390 CHAIN BRIDGE RD # 50032
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3904
Mailing Address - Country:US
Mailing Address - Phone:703-520-7878
Mailing Address - Fax:
Practice Address - Street 1:8504 LAROQUE RUN DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-1932
Practice Address - Country:US
Practice Address - Phone:703-520-7878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty