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General NPI Number Information
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NPI Number | 1760247639
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Entity Type | Organization
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Legal Business Name | EVERGREEN INTEGRATIVE MENTAL HEALTH CARE
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Dates
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Enumeration Date | 02/19/2024
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Last Update Date | 02/19/2024
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Provider Practice Location Address
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Address Line | 111 SHOSHONE ST N STE 202
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City | TWIN FALLS
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State | ID
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Zip | 83301-6119
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Country | US
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Telephone | 208-490-2082
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Fax | 208-718-1106
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Provider Business Mailing Address
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Address Line | 595 MT VIEW DR
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City | TWIN FALLS
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State | ID
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Zip | 83301-4319
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Country | US
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Telephone | 208-490-2082
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. SHEILA MARIE GREEN
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Credential | LCPC
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Telephone | 208-490-2082
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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 |
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License Number State |
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