Provider Demographics
NPI:1568258861
Name:SELF-EVOLUTION COUNSELING & CLINICAL CONSULTATION, LLC
Entity type:Organization
Organization Name:SELF-EVOLUTION COUNSELING & CLINICAL CONSULTATION, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPC/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:RENEA
Authorized Official - Last Name:GREGG-MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, LMHP
Authorized Official - Phone:804-252-1862
Mailing Address - Street 1:700 E 6TH ST # L
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23224-5560
Mailing Address - Country:US
Mailing Address - Phone:804-252-1862
Mailing Address - Fax:804-655-6171
Practice Address - Street 1:700 E 6TH ST # L
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23224-5560
Practice Address - Country:US
Practice Address - Phone:804-252-1862
Practice Address - Fax:804-655-6171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty