Healthcare Provider Details

I. General information

NPI: 1669283545
Provider Name (Legal Business Name): EVERGREEN WELLNESS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2025
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 MCKINLEY AVE
KELLOGG ID
83837-2501
US

IV. Provider business mailing address

123 MCKINLEY AVE
KELLOGG ID
83837-2501
US

V. Phone/Fax

Practice location:
  • Phone: 208-512-2522
  • Fax:
Mailing address:
  • Phone: 208-512-2522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MEGHANN JOHNSON
Title or Position: CEO
Credential: LCSW
Phone: 208-512-2522