Provider Demographics
NPI:1275066490
Name:EVERGREEN IN HOME MENTAL HEALTH
Entity Type:Organization
Organization Name:EVERGREEN IN HOME MENTAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEAH
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:SW
Authorized Official - Phone:425-899-6308
Mailing Address - Street 1:12040 NE 128TH ST
Mailing Address - Street 2:MS 74
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3013
Mailing Address - Country:US
Mailing Address - Phone:425-899-6300
Mailing Address - Fax:425-899-6301
Practice Address - Street 1:12040 NE 128TH ST
Practice Address - Street 2:MS 74
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3013
Practice Address - Country:US
Practice Address - Phone:425-899-6300
Practice Address - Fax:425-899-6301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-05
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH 60152884251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health