Healthcare Provider Details

I. General information

NPI: 1043828825
Provider Name (Legal Business Name): EVERGREEN THERAPY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2020
Last Update Date: 11/22/2025
Certification Date: 11/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 ASHLEY CT STE 5
NORTH LIBERTY IA
52317-4758
US

IV. Provider business mailing address

595 ASHLEY CT STE 5
NORTH LIBERTY IA
52317-4758
US

V. Phone/Fax

Practice location:
  • Phone: 319-853-8762
  • Fax: 319-249-6875
Mailing address:
  • Phone: 319-853-8762
  • Fax: 319-249-6875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JASON MATTHEW DRWAL
Title or Position: PRESIDENT
Credential: PH.D.
Phone: 319-853-8762