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General NPI Number Information
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NPI Number | 1831520543
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Entity Type | Organization
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Legal Business Name | EVERGREEN BEHAVIORAL HEALTH
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Dates
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Enumeration Date | 12/05/2013
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Last Update Date | 12/05/2013
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Provider Practice Location Address
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Address Line | 226 EVERGREEN DR
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City | BOISE
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State | ID
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Zip | 83716-3024
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Country | US
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Telephone | 208-890-3787
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Fax | 208-350-4379
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Provider Business Mailing Address
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Address Line | 226 EVERGREEN DR
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City | BOISE
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State | ID
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Zip | 83716-3024
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Country | US
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Telephone | 208-890-3787
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Fax | 208-350-4379
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Authorized Official
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Title or Position | COUNSELOR
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Name | MR. BRYAN WILLIAM BEDDOES
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Credential | LPC
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Telephone | 208-890-3787
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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 | LPC-5105
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License Number State | ID
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