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General NPI Number Information
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NPI Number | 1669926556
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Entity Type | Organization
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Legal Business Name | EVERGREEN PSYCHIATRY, LLC
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Dates
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Enumeration Date | 08/08/2016
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Last Update Date | 08/08/2016
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Provider Practice Location Address
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Address Line | 801 SAMISH WAY
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City | BELLINGHAM
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State | WA
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Zip | 98229-2901
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Country | US
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Telephone | 360-255-2505
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Fax |
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Provider Business Mailing Address
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Address Line | 801 SAMISH WAY
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City | BELLINGHAM
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State | WA
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Zip | 98229-2901
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | AMBER KOSTIAL
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Credential | MD
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Telephone | 801-635-9580
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 60564652
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License Number State | WA
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