Provider Demographics
NPI:1043828825
Name:EVERGREEN THERAPY CENTER LLC
Entity type:Organization
Organization Name:EVERGREEN THERAPY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:DRWAL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:319-853-8762
Mailing Address - Street 1:595 ASHLEY CT STE 5
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-4758
Mailing Address - Country:US
Mailing Address - Phone:319-853-8762
Mailing Address - Fax:319-249-6875
Practice Address - Street 1:595 ASHLEY CT STE 5
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-4758
Practice Address - Country:US
Practice Address - Phone:319-853-8762
Practice Address - Fax:319-249-6875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-17
Last Update Date:2025-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health