Healthcare Provider Details

I. General information

NPI: 1831681600
Provider Name (Legal Business Name): EVERGREEN COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 MANCHESTER RD STE 602
WHEATON IL
60187-4587
US

IV. Provider business mailing address

2100 MANCHESTER RD STE 602
WHEATON IL
60187-4587
US

V. Phone/Fax

Practice location:
  • Phone: 213-222-5079
  • Fax:
Mailing address:
  • Phone: 630-480-0060
  • Fax: 630-981-2094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number166.001114
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NATASHA KNOFF
Title or Position: PRACTICE MANAGER
Credential: LMFT
Phone: 213-222-5079