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General NPI Number Information
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NPI Number | 1629957626
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Entity Type | Organization
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Legal Business Name | EVERGREEN THERAPY LLC
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Dates
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Enumeration Date | 09/02/2025
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 105 N 40TH AVE
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City | HATTIESBURG
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State | MS
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Zip | 39401-6606
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Country | US
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Telephone | 769-390-7929
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Fax |
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Provider Business Mailing Address
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Address Line | 103 FOX TER
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City | HATTIESBURG
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State | MS
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Zip | 39402-1813
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Country | US
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Telephone | 601-408-5946
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Fax |
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Authorized Official
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Title or Position | COUNSELOR/OWNER
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Name | VICTORIA LAUREN ALEXANDER
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Credential |
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Telephone | 601-408-5946
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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