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General NPI Number Information
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NPI Number | 1558128553
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Entity Type | Organization
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Legal Business Name | EVERGREEN ABA LLC
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Dates
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Enumeration Date | 03/05/2024
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Last Update Date | 11/07/2024
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Provider Practice Location Address
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Address Line | 900 SE 5TH STREET
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City | BENTONVILLE
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State | AR
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Zip | 72712
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Country | US
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Telephone | 314-410-9670
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Fax |
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Provider Business Mailing Address
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Address Line | 8130 BALSON AVE.
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City | ST. LOUIS
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State | MO
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Zip | 63130
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Country | US
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Telephone | 314-410-9670
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Fax | 855-611-8213
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Authorized Official
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Title or Position | CEO
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Name | TALIA SCHUSS
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Credential |
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Telephone | 314-410-9670
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number |
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License Number State |
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