Healthcare Provider Details

I. General information

NPI: 1598342842
Provider Name (Legal Business Name): EVERGREEN THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2021
Last Update Date: 03/24/2021
Certification Date: 03/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 N FOSTER AVE
LANSING MI
48912-4305
US

IV. Provider business mailing address

PO BOX 10
MASON MI
48854-0010
US

V. Phone/Fax

Practice location:
  • Phone: 517-803-0078
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name: MARYBETH HOUPT
Title or Position: CREDENTIALING
Credential:
Phone: 517-676-9788