Healthcare Provider Details

I. General information

NPI: 1700698164
Provider Name (Legal Business Name): EVERGREEN PSYCHIATRY GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2025
Last Update Date: 01/23/2025
Certification Date: 01/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

717 GREEN VALLEY RD STE 200
GREENSBORO NC
27408-2156
US

IV. Provider business mailing address

717 GREEN VALLEY RD STE 200
GREENSBORO NC
27408-2156
US

V. Phone/Fax

Practice location:
  • Phone: 743-222-9755
  • Fax:
Mailing address:
  • Phone: 743-222-9755
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MARIAM NANTANG
Title or Position: OWNER
Credential:
Phone: 743-222-9755