Provider Demographics
NPI:1497980338
Name:EVERGREEN SOUTHWEST BEHAVIORAL HEALTH SERVICES LLC
Entity type:Organization
Organization Name:EVERGREEN SOUTHWEST BEHAVIORAL HEALTH SERVICES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COO/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:DARLENE
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:513-531-6444
Mailing Address - Street 1:2 MIRANOVA PL
Mailing Address - Street 2:SUITE 310
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-5078
Mailing Address - Country:US
Mailing Address - Phone:614-334-6196
Mailing Address - Fax:614-461-7168
Practice Address - Street 1:5500 VERULAM AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45213-2418
Practice Address - Country:US
Practice Address - Phone:513-531-6444
Practice Address - Fax:513-531-9444
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EVERGREEN SOUTHWEST BEHAVIORALHEALTH SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-21
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH283Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital