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General NPI Number Information
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NPI Number | 1992152821
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Entity Type | Organization
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Legal Business Name | EVERGREEN RECOVERY
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Dates
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Enumeration Date | 05/20/2016
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Last Update Date | 03/11/2020
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Provider Practice Location Address
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Address Line | 1400 ENERGY PARK DR SUITE 21
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City | SAINT PAUL
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State | MN
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Zip | 55108-5272
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Country | US
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Telephone | 651-252-6070
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Fax | 651-252-6071
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Provider Business Mailing Address
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Address Line | 1400 ENERGY PARK DR SUITE 21
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City | SAINT PAUL
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State | MN
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Zip | 55108-5272
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Country | US
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Telephone | 651-252-6070
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Fax | 651-252-6071
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DAVID BACKUS
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Credential |
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Telephone | 651-252-6070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 303683
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 303672
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License Number State | MN
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 1204
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License Number State | MN
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Taxonomy #4
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 304003
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License Number State | MN
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Taxonomy #5
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State |
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