=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700087509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN COUNSELING SVS.,
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 82 PALOMINO LN SUITE 702
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03110-6448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-626-5400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 82 PALOMINO LN SUITE 702
-----------------------------------------------------
City | BEDFORD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03110-6448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-626-5400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MS. DONNA GULDENSTERN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 603-626-5400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 11
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------