Provider Demographics
NPI:1073225090
Name:EVERGREEN MENTAL HEALTH & ASSESSMENT, LLC
Entity Type:Organization
Organization Name:EVERGREEN MENTAL HEALTH & ASSESSMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:HINNEBUSCH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:240-274-0012
Mailing Address - Street 1:4758 LYNNVILLE WAY
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-8990
Mailing Address - Country:US
Mailing Address - Phone:240-274-0012
Mailing Address - Fax:
Practice Address - Street 1:4758 LYNNVILLE WAY
Practice Address - Street 2:
Practice Address - City:CLAY
Practice Address - State:NY
Practice Address - Zip Code:13041-8990
Practice Address - Country:US
Practice Address - Phone:240-274-0012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental HealthGroup - Multi-Specialty