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General NPI Number Information
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NPI Number | 1932368628
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Entity Type | Organization
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Legal Business Name | EVERGREEN PSYCHOLOGY, LLC
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Dates
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Enumeration Date | 06/06/2008
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Last Update Date | 06/06/2008
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Provider Practice Location Address
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Address Line | 235 W PATRICK ST
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City | FREDERICK
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State | MD
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Zip | 21701-6934
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Country | US
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Telephone | 301-662-4160
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Fax | 301-620-4344
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Provider Business Mailing Address
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Address Line | 235 W PATRICK ST
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City | FREDERICK
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State | MD
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Zip | 21701-6934
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Country | US
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Telephone | 301-662-4160
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Fax | 301-620-4344
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ROBERT F MANNIS
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Credential | PHD
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Telephone | 301-662-4160
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number |
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License Number State |
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