Healthcare Provider Details

I. General information

NPI: 1467063875
Provider Name (Legal Business Name): EVERGREEN WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2020
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 HIGHLAND ST APT 303
TAUNTON MA
02780-4446
US

IV. Provider business mailing address

PO BOX 767
WEST WARWICK RI
02893-0610
US

V. Phone/Fax

Practice location:
  • Phone: 508-386-2094
  • Fax: 508-967-7194
Mailing address:
  • Phone: 508-386-2094
  • Fax: 508-967-7194

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: DR. REBECCA NILI UTH
Title or Position: MANAGER
Credential: PSYD
Phone: 508-386-2094