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General NPI Number Information
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NPI Number | 1033814058
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Entity Type | Organization
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Legal Business Name | EVERGREEN COUNSELING AND YOGA THERAPY
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Dates
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Enumeration Date | 03/31/2023
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Last Update Date | 03/31/2023
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Provider Practice Location Address
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Address Line | 505 28TH ST
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City | VIENNA
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State | WV
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Zip | 26105-1451
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Country | US
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Telephone | 304-295-4484
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Fax |
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Provider Business Mailing Address
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Address Line | 505 28TH ST
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City | VIENNA
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State | WV
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Zip | 26105-1451
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Country | US
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Telephone | 304-295-4484
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | NICOLE MARTIN
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Credential | LPC
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Telephone | 304-295-4484
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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