Provider Demographics
NPI:1073879177
Name:EVERGREEN BEHAVIORAL HEALTH SERVICES,LLC
Entity Type:Organization
Organization Name:EVERGREEN BEHAVIORAL HEALTH SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:WYMAN
Authorized Official - Suffix:
Authorized Official - Credentials:EDM, NCC, LPC
Authorized Official - Phone:540-937-4923
Mailing Address - Street 1:PO BOX 373
Mailing Address - Street 2:
Mailing Address - City:RIXEYVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22737-0373
Mailing Address - Country:US
Mailing Address - Phone:540-937-4923
Mailing Address - Fax:540-937-7680
Practice Address - Street 1:10391 GREYSON LN
Practice Address - Street 2:
Practice Address - City:RIXEYVILLE
Practice Address - State:VA
Practice Address - Zip Code:22737-1730
Practice Address - Country:US
Practice Address - Phone:540-937-4923
Practice Address - Fax:540-937-7680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-03
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701003919101YM0800X, 101YP2500X, 101YS0200X, 106H00000X, 171M00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Single Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA01619872OtherANTHEM