Healthcare Provider Details

I. General information

NPI: 1083013999
Provider Name (Legal Business Name): EVERGREEN MENTAL HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 RIDGELY ST SUITE 100
BALTIMORE MD
21230-2050
US

IV. Provider business mailing address

9318 GAITHER RD STE 220
GAITHERSBURG MD
20877-1407
US

V. Phone/Fax

Practice location:
  • Phone: 240-251-4702
  • Fax: 301-251-4703
Mailing address:
  • Phone: 240-251-4702
  • Fax: 301-251-4703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: BARTON AZWALINSKY
Title or Position: CEO
Credential:
Phone: 301-251-4702