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NPI Code Detail

MEDICARE: EVERGREEN THERAPY GROUP, LLC

MEDICARE: EVERGREEN THERAPY GROUP, 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
11041C0700XClinical Social Worker

General Provider Information

NPI Number : 1942079553
Entity Type Code : Organization
Provider Name (Legal Business Name) : EVERGREEN THERAPY GROUP, LLC
Provider Business Mailing Address
First Line : 20156 CAMELLIA CROSSE LN
Second Line :
City : ESTERO
State : FL
Zip : 33928-4062
Country : US
Telephone Number : 240-478-8092
Fax Number :
Provider Business Practice Location Address
First Line : 11 BYTE CT STE C
Second Line :
City : FREDERICK
State : MD
Zip : 21702-8718
Country : US
Telephone Number : 240-478-8092
Fax Number :
Authorized Official
Title or Position : OWNER AND PSYCHOTHERAPIST
Name : MICHELLE RIZK BAVENDER
Credential : LCSW-C
Telephone Number : 240-478-8092
Provider Enumeration Date : 12/22/2023
Last Update Date : 12/22/2023

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Directions to “EVERGREEN THERAPY GROUP, LLC ” Practice Location

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