Provider Demographics
NPI:1205646239
Name:EVERGREEN AUTISM SERVICES LLC
Entity type:Organization
Organization Name:EVERGREEN AUTISM SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIOR ANALYST
Authorized Official - Prefix:
Authorized Official - First Name:TONYA
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA, COBA
Authorized Official - Phone:937-723-0212
Mailing Address - Street 1:1421 SEMINOLE DR
Mailing Address - Street 2:
Mailing Address - City:XENIA
Mailing Address - State:OH
Mailing Address - Zip Code:45385-4355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1421 SEMINOLE DR
Practice Address - Street 2:
Practice Address - City:XENIA
Practice Address - State:OH
Practice Address - Zip Code:45385-4355
Practice Address - Country:US
Practice Address - Phone:937-723-0212
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-11
Last Update Date:2025-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty