Provider Demographics
NPI:1467134403
Name:EVERGREEN ASSESSMENT & CONSULTATION LLC
Entity Type:Organization
Organization Name:EVERGREEN ASSESSMENT & CONSULTATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:THOMAS-STAGG
Authorized Official - Suffix:
Authorized Official - Credentials:PSYCHOLOGIST
Authorized Official - Phone:217-714-7042
Mailing Address - Street 1:411 E PARK ST STE 106
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3862
Mailing Address - Country:US
Mailing Address - Phone:217-714-7042
Mailing Address - Fax:866-216-6514
Practice Address - Street 1:411 E PARK ST STE 106
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-3862
Practice Address - Country:US
Practice Address - Phone:217-714-7042
Practice Address - Fax:866-216-6514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty