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General NPI Number Information
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NPI Number | 1578789020
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Entity Type | Organization
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Legal Business Name | EVERGREEN COUNSELING, INC.
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5300 W SAHARA AVE SUITE 104
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City | LAS VEGAS
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State | NV
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Zip | 89146-0353
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Country | US
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Telephone | 702-248-6290
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Fax | 702-248-4720
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Provider Business Mailing Address
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Address Line | 5300 W SAHARA AVE SUITE 104
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City | LAS VEGAS
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State | NV
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Zip | 89146-0353
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Country | US
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Telephone | 702-248-6290
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Fax | 702-248-4720
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | MR. THOMAS C WAGNER
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Credential | LCSW
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Telephone | 702-248-6290
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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 | 01761-C
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License Number State | NV
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