Provider Demographics
NPI:1487341848
Name:EMERGE AND EVOLVE THERAPY PLLC
Entity type:Organization
Organization Name:EMERGE AND EVOLVE THERAPY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:PROVENZOLA
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-385-2524
Mailing Address - Street 1:4902 CHILSON RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-9453
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4902 CHILSON RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-9453
Practice Address - Country:US
Practice Address - Phone:248-385-2524
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty