Provider Demographics
NPI:1891494779
Name:EVERGREEN THERAPY, PLLC
Entity Type:Organization
Organization Name:EVERGREEN THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JOBETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MUSICK
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:501-425-4039
Mailing Address - Street 1:1101 WINNEBAGO DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72116-4350
Mailing Address - Country:US
Mailing Address - Phone:501-425-4039
Mailing Address - Fax:
Practice Address - Street 1:7514 HIGHWAY 107
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-7212
Practice Address - Country:US
Practice Address - Phone:501-392-6681
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1659722528Medicaid
AR1306194485Medicaid