Healthcare Provider Details

I. General information

NPI: 1568858363
Provider Name (Legal Business Name): EVERGREEN MOUNTAINS THERAPY AND CONSULTING, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2015
Last Update Date: 04/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 17TH ST
OREGON CITY OR
97045-1032
US

IV. Provider business mailing address

309 17TH ST
OREGON CITY OR
97045-1032
US

V. Phone/Fax

Practice location:
  • Phone: 503-260-0969
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberL6297
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DAVID W SANT
Title or Position: ADMINISTRATOR
Credential: MSW, LCSW
Phone: 503-260-0969