Provider Demographics
NPI:1083013999
Name:EVERGREEN MENTAL HEALTH SERVICES, INC.
Entity Type:Organization
Organization Name:EVERGREEN MENTAL HEALTH SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BARTON
Authorized Official - Middle Name:
Authorized Official - Last Name:AZWALINSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-251-4702
Mailing Address - Street 1:9318 GAITHER RD STE 220
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-1407
Mailing Address - Country:US
Mailing Address - Phone:240-251-4702
Mailing Address - Fax:301-251-4703
Practice Address - Street 1:1645 RIDGELY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-2050
Practice Address - Country:US
Practice Address - Phone:240-251-4702
Practice Address - Fax:301-251-4703
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN MENTAL HEALTH SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B99125Medicare UPIN