Provider Demographics
NPI:1508133836
Name:EVERGREEN PEDIATRIC GROUP, INC
Entity Type:Organization
Organization Name:EVERGREEN PEDIATRIC GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MA, BCBA, LPC
Authorized Official - Phone:815-985-3882
Mailing Address - Street 1:157 REDMOND DR
Mailing Address - Street 2:
Mailing Address - City:GILBERTS
Mailing Address - State:IL
Mailing Address - Zip Code:60136-8026
Mailing Address - Country:US
Mailing Address - Phone:815-985-3882
Mailing Address - Fax:
Practice Address - Street 1:157 REDMOND DR
Practice Address - Street 2:
Practice Address - City:GILBERTS
Practice Address - State:IL
Practice Address - Zip Code:60136-8026
Practice Address - Country:US
Practice Address - Phone:815-985-3882
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-01
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1-11-9409251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health