Healthcare Provider Details

I. General information

NPI: 1184376048
Provider Name (Legal Business Name): EVERGREEN PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 BLACK LAKE BLVD SW # 102
OLYMPIA WA
98512-5651
US

IV. Provider business mailing address

1930 BLACK LAKE BLVD SW # 102
OLYMPIA WA
98512-5651
US

V. Phone/Fax

Practice location:
  • Phone: 360-347-6172
  • Fax: 360-350-4619
Mailing address:
  • Phone: 360-347-6172
  • Fax: 360-350-4619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. EVAN LIMA
Title or Position: OWNER
Credential: PHD
Phone: 360-347-6172