Healthcare Provider Details

I. General information

NPI: 1639879141
Provider Name (Legal Business Name): EVERGREEN BEHAVIORAL HEALTH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1431 LIBERTY ST SE
SALEM OR
97302-4343
US

IV. Provider business mailing address

960 LIBERTY ST SE STE 110
SALEM OR
97302-4165
US

V. Phone/Fax

Practice location:
  • Phone: 503-383-1613
  • Fax:
Mailing address:
  • Phone: 503-383-1613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: RACHEL MARTIN
Title or Position: OWNER
Credential:
Phone: 612-598-9227