Provider Demographics
NPI:1336752021
Name:EVERGREEN WELLNESS PSYCHOTHERAPY
Entity Type:Organization
Organization Name:EVERGREEN WELLNESS PSYCHOTHERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSOLEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-870-2198
Mailing Address - Street 1:18507 89TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-2827
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:209 MAIN AVE S STE 115
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:WA
Practice Address - Zip Code:98045-8139
Practice Address - Country:US
Practice Address - Phone:425-870-2198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service