Provider Demographics
NPI:1467063875
Name:EVERGREEN WELLNESS CENTER, LLC
Entity Type:Organization
Organization Name:EVERGREEN WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:NILI
Authorized Official - Last Name:UTH
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:508-386-2094
Mailing Address - Street 1:PO BOX 767
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893-0610
Mailing Address - Country:US
Mailing Address - Phone:508-386-2094
Mailing Address - Fax:508-967-7194
Practice Address - Street 1:171 HIGHLAND ST APT 303
Practice Address - Street 2:
Practice Address - City:TAUNTON
Practice Address - State:MA
Practice Address - Zip Code:02780-4446
Practice Address - Country:US
Practice Address - Phone:508-386-2094
Practice Address - Fax:508-967-7194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110165840AMedicaid