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General NPI Number Information
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NPI Number | 1518452374
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Entity Type | Organization
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Legal Business Name | EVERGREEN THERAPY CONNECTIONS, LLC
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Dates
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Enumeration Date | 06/25/2018
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Last Update Date | 06/25/2018
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Provider Practice Location Address
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Address Line | 520 20TH ST APT 1
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City | WASHOUGAL
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State | WA
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Zip | 98671-1563
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Country | US
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Telephone | 971-319-0687
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Fax |
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Provider Business Mailing Address
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Address Line | 520 20TH ST APT 1
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City | WASHOUGAL
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State | WA
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Zip | 98671-1563
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Country | US
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Telephone | 971-319-0687
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Fax |
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Authorized Official
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Title or Position | OWNER/SPEECH PATHOLOGIST
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Name | ALYSSA L FUGGITI
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Credential | MA CCC-SLP
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Telephone | 971-319-0687
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0700X
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Taxonomy Name | Hearing and Speech Clinic/Center
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License Number | LL60607604
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License Number State | WA
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