MEDICARE: EVERGROVE THERAPY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1558227173
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGROVE THERAPY LLC

Provider Business Mailing Address
First Line	:	5442 MAJESTIC DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-3540
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5442 MAJESTIC DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-3540
Country	:	US
Telephone Number	:	214-732-2497
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	RYAN ANDREA MARTINEZ
Credential	:	BCBA
Telephone Number	:	214-732-2497

Provider Enumeration Date	:	12/29/2025
Last Update Date	:	12/29/2025

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Directions to “EVERGROVE THERAPY LLC ” Practice Location

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