MEDICARE: EVERGREEN HEALTHCARE CLINIC LIMITED LIABILITY COMPANY

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1659162402
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EVERGREEN HEALTHCARE CLINIC LIMITED LIABILITY COMPANY

Provider Business Mailing Address
First Line	:	13707 CROWNSGATE WAY
Second Line	:
City	:	GERMANTOWN
State	:	MD
Zip	:	20874-4424
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 INDIAN GRASS CT
Second Line	:
City	:	GERMANTOWN
State	:	MD
Zip	:	20874-2930
Country	:	US
Telephone Number	:	240-644-5570
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	YVETTE LEDJO
Credential	:
Telephone Number	:	240-644-5570

Provider Enumeration Date	:	05/13/2025
Last Update Date	:	05/13/2025

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