Provider Demographics
NPI:1639615206
Name:EVERGREEN PSYCHOLOGICAL SERVICES, LLC
Entity Type:Organization
Organization Name:EVERGREEN PSYCHOLOGICAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT/BUSINESS ADMINISTRAT
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:A
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LMHC, LICDC, MAC
Authorized Official - Phone:317-520-4650
Mailing Address - Street 1:1155 PARKWAY DR. STE 200
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-8541
Mailing Address - Country:US
Mailing Address - Phone:317-520-4650
Mailing Address - Fax:
Practice Address - Street 1:1155 PARKWAY DR. STE 200
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-8541
Practice Address - Country:US
Practice Address - Phone:317-520-4650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-06
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39001948A101YM0800X
IN20042335A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201002540Medicaid