Provider Demographics
NPI:1578008462
Name:EVERGREEN RECOVERY CENTER
Entity Type:Organization
Organization Name:EVERGREEN RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHEMICAL DEPENDENCY PROFESSIONAL
Authorized Official - Prefix:MISS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:PEARSON
Authorized Official - Suffix:
Authorized Official - Credentials:CDP
Authorized Official - Phone:425-322-0821
Mailing Address - Street 1:5620 183RD ST SW APT 107
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98037-7319
Mailing Address - Country:US
Mailing Address - Phone:206-678-6434
Mailing Address - Fax:
Practice Address - Street 1:2601 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3309
Practice Address - Country:US
Practice Address - Phone:425-258-2407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-30
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP603443013245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children