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General NPI Number Information
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NPI Number | 1447314539
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Entity Type | Organization
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Legal Business Name | THE EVERGREEN CLINIC
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Dates
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Enumeration Date | 12/21/2006
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Last Update Date | 04/27/2015
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Provider Practice Location Address
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Address Line | 12025 115TH AVE NE #200
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City | KIRKLAND
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State | WA
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Zip | 98034
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Country | US
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Telephone | 425-821-1810
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Fax | 425-823-1231
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Provider Business Mailing Address
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Address Line | 12025 115TH AVE NE #200
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City | KIRKLAND
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State | WA
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Zip | 98034
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Country | US
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Telephone | 425-821-1810
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Fax | 425-823-1231
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Authorized Official
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Title or Position | OWNER
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Name | ANNE R. LUCAS
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Credential | LMHC
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Telephone | 425-821-1810
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 601889816
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License Number State | WA
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