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General NPI Number Information
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NPI Number | 1154412492
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Entity Type | Organization
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Legal Business Name | EVERGREEN BEHAVIORAL HEALTH CENTER, INC.
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Dates
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Enumeration Date | 09/28/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 240 NORTH ST
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City | NEW MARTINSVILLE
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State | WV
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Zip | 26155-1771
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Country | US
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Telephone | 304-455-4415
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Fax | 304-455-2501
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Provider Business Mailing Address
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Address Line | 240 NORTH ST
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City | NEW MARTINSVILLE
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State | WV
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Zip | 26155-1771
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Country | US
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Telephone | 304-455-4415
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Fax | 304-455-2501
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MR. B. MARK FETTY
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Credential | AB
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Telephone | 304-455-4415
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number | 112
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License Number State | WV
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