Provider Demographics
NPI:1033814058
Name:EVERGREEN COUNSELING AND YOGA THERAPY
Entity Type:Organization
Organization Name:EVERGREEN COUNSELING AND YOGA THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:304-295-4484
Mailing Address - Street 1:505 28TH ST
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-1451
Mailing Address - Country:US
Mailing Address - Phone:304-295-4484
Mailing Address - Fax:
Practice Address - Street 1:505 28TH ST
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:WV
Practice Address - Zip Code:26105-1451
Practice Address - Country:US
Practice Address - Phone:304-295-4484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty