Provider Demographics
NPI:1386260289
Name:EVOLVE WELLNESS CENTRE, LLC
Entity type:Organization
Organization Name:EVOLVE WELLNESS CENTRE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHALANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:JUDGE
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:225-206-4060
Mailing Address - Street 1:9080 GREENWELL ST
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70812-2519
Mailing Address - Country:US
Mailing Address - Phone:225-206-4060
Mailing Address - Fax:225-372-8649
Practice Address - Street 1:9080 GREENWELL ST
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70812-2519
Practice Address - Country:US
Practice Address - Phone:225-206-4060
Practice Address - Fax:225-372-8649
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVOLVE WELLNESS CENTRE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-17
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty