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General NPI Number Information
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NPI Number | 1467134403
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Entity Type | Organization
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Legal Business Name | EVERGREEN ASSESSMENT & CONSULTATION LLC
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Dates
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Enumeration Date | 08/01/2023
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Last Update Date | 08/01/2023
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Provider Practice Location Address
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Address Line | 411 E PARK ST STE 106
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City | CHAMPAIGN
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State | IL
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Zip | 61820-3862
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Country | US
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Telephone | 217-714-7042
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Fax | 866-216-6514
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Provider Business Mailing Address
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Address Line | 411 E PARK ST STE 106
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City | CHAMPAIGN
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State | IL
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Zip | 61820-3862
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Country | US
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Telephone | 217-714-7042
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Fax | 866-216-6514
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Authorized Official
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Title or Position | OWNER
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Name | DR. JONATHAN WILLIAM THOMAS-STAGG
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Credential | PSYCHOLOGIST
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Telephone | 217-714-7042
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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