Healthcare Provider Details

I. General information

NPI: 1720665987
Provider Name (Legal Business Name): EVERGREEN THERAPEUTIC TREATMENT CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 PARK CENTER DR
PARKERSBURG WV
26101-1929
US

IV. Provider business mailing address

322 46TH ST
VIENNA WV
26105-1822
US

V. Phone/Fax

Practice location:
  • Phone: 419-733-3889
  • Fax:
Mailing address:
  • Phone: 419-733-3889
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMIE TUTTLE
Title or Position: CHIEF EXECUTIVE OF OPERATIONS
Credential: LPCC-S
Phone: 419-733-3889