Healthcare Provider Details

I. General information

NPI: 1790950657
Provider Name (Legal Business Name): EVERGREEN COUNSELING SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 06/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 INDUSTRIAL PARK RD MAILBOX #29, SUITE 211
VANDERGRIFT PA
15690-9646
US

IV. Provider business mailing address

PO BOX 472
NATRONA HEIGHTS PA
15065-0472
US

V. Phone/Fax

Practice location:
  • Phone: 724-845-9880
  • Fax:
Mailing address:
  • Phone: 724-845-9880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberPC003332
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberCW013339
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPS016983
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPS016983
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberPS016983
License Number StatePA
# 6
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPS016983
License Number StatePA
# 7
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPS016983
License Number StatePA
# 8
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW013339
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: STEPHEN A BRUNETTI
Title or Position: PRESIDENT
Credential: L.C.S.W.
Phone: 724-845-9880