Provider Demographics
NPI:1194304931
Name:EVOLVING LIGHT COUNSELING LLC
Entity type:Organization
Organization Name:EVOLVING LIGHT COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:LAUREY
Authorized Official - Middle Name:
Authorized Official - Last Name:RAY
Authorized Official - Suffix:
Authorized Official - Credentials:CMBS
Authorized Official - Phone:702-279-7270
Mailing Address - Street 1:32 E 100 S STE 202
Mailing Address - Street 2:
Mailing Address - City:ST GEORGE
Mailing Address - State:UT
Mailing Address - Zip Code:84770-3495
Mailing Address - Country:US
Mailing Address - Phone:435-668-4956
Mailing Address - Fax:702-566-4575
Practice Address - Street 1:32 E 100 S STE 202
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84770-3495
Practice Address - Country:US
Practice Address - Phone:435-668-4956
Practice Address - Fax:702-566-4575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT193400000XMedicaid