Provider Demographics
NPI:1881039451
Name:EVERGREEN THERAPY LLC
Entity Type:Organization
Organization Name:EVERGREEN THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:DARREN MATSUO
Authorized Official - Last Name:PEDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OTR
Authorized Official - Phone:303-579-0322
Mailing Address - Street 1:601 GRIFFIN PL
Mailing Address - Street 2:APT A
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80521-1896
Mailing Address - Country:US
Mailing Address - Phone:303-579-0322
Mailing Address - Fax:
Practice Address - Street 1:601 GRIFFIN PL
Practice Address - Street 2:APT A
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80521-1896
Practice Address - Country:US
Practice Address - Phone:303-579-0322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-08
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3123225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty