Provider Demographics
NPI:1316708993
Name:EVOLVE BEHAVIORAL HEALTH, LLC
Entity type:Organization
Organization Name:EVOLVE BEHAVIORAL HEALTH, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO- OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JESSI
Authorized Official - Middle Name:BLACKSTOCK
Authorized Official - Last Name:TIDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:256-394-0880
Mailing Address - Street 1:2904 MALL RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35630-1641
Mailing Address - Country:US
Mailing Address - Phone:256-767-3330
Mailing Address - Fax:949-695-4340
Practice Address - Street 1:2904 MALL RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35630-1641
Practice Address - Country:US
Practice Address - Phone:256-767-3330
Practice Address - Fax:949-695-4340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-19
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty