1730043423 NPI number — EVOLUTION CLINICAL COUNSELING AND SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730043423 NPI number — EVOLUTION CLINICAL COUNSELING AND SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVOLUTION CLINICAL COUNSELING AND SERVICES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730043423
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
751 CHOCTAW ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRENADA
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38901-5317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
662-614-4441
Provider Business Mailing Address Fax Number:
601-510-7558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
149C GREEN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRENADA
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38901-2618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-614-4441
Provider Business Practice Location Address Fax Number:
601-510-7558
Provider Enumeration Date:
12/16/2025

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
ANGELA
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
CLINICIAN/OWNER
Authorized Official Telephone Number:
662-614-4441

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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