| Evolution Mind, Llc | |
|
2130 Millburn Ave Ste D2 Maplewood NJ 07040-3749 | |
| (973) 801-1801 | |
| (908) 964-0809 |
| Full Name | Evolution Mind, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 2130 Millburn Ave Ste D2, Maplewood, New Jersey |
| Authorized Official Name and Position | Kira Baskerville-williams (CO-OWNER) |
| Authorized Official Contact | 9738011801 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Evolution Mind, Llc 1286 Marcella Dr Union NJ 07083-6243 Ph: (973) 801-1801 | Evolution Mind, Llc 2130 Millburn Ave Ste D2 Maplewood NJ 07040-3749 Ph: (973) 801-1801 |
| NPI Number | 1912428905 |
|---|---|
| Provider Enumeration Date | 06/29/2017 |
| Last Update Date | 10/23/2017 |
| Medicare PECOS PAC ID | 7719308824 |
|---|---|
| Medicare Enrollment ID | O20200528000028 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1912428905 | NPI | - | NPPES |
| 1336699529 | Other | NJ | NPI |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0801X | Clinic/center - Mental Health (including Community Mental Health Center) | (* (Not Available)) | Primary |
| Provider Name | Kira L Baskerville-williams |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1336699529 PECOS PAC ID: 6204118292 Enrollment ID: I20170127000657 |
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