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General NPI Number Information
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NPI Number | 1639615206
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Entity Type | Organization
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Legal Business Name | EVERGREEN PSYCHOLOGICAL SERVICES, LLC
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Dates
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Enumeration Date | 01/06/2017
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Last Update Date | 04/11/2017
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Provider Practice Location Address
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Address Line | 1155 PARKWAY DR. STE 200
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City | ZIONSVILLE
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State | IN
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Zip | 46077-8541
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Country | US
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Telephone | 317-520-4650
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Fax |
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Provider Business Mailing Address
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Address Line | 1155 PARKWAY DR. STE 200
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City | ZIONSVILLE
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State | IN
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Zip | 46077-8541
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Country | US
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Telephone | 317-520-4650
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Fax |
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Authorized Official
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Title or Position | VICE PRESIDENT/BUSINESS ADMINISTRAT
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Name | MR. RANDALL A. YOUNG
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Credential | MA, LMHC, LICDC, MAC
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Telephone | 317-520-4650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 39001948A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 20042335A
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License Number State | IN
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