Provider Demographics
NPI:1194233718
Name:THE EVOLVING CHAIR COUNSELING AND CONSULTING AGENCY
Entity type:Organization
Organization Name:THE EVOLVING CHAIR COUNSELING AND CONSULTING AGENCY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHILD & FAMILY THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:LAKIESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:414-395-0037
Mailing Address - Street 1:7425 W FLORIST AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-1850
Mailing Address - Country:US
Mailing Address - Phone:414-748-1614
Mailing Address - Fax:
Practice Address - Street 1:3100 N 78TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-3916
Practice Address - Country:US
Practice Address - Phone:414-395-0037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6098-125251S00000X, 261QM0801X, 261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health