Provider Demographics
NPI:1831520543
Name:EVERGREEN BEHAVIORAL HEALTH
Entity type:Organization
Organization Name:EVERGREEN BEHAVIORAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:BEDDOES
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:208-890-3787
Mailing Address - Street 1:226 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-3024
Mailing Address - Country:US
Mailing Address - Phone:208-890-3787
Mailing Address - Fax:208-350-4379
Practice Address - Street 1:226 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-3024
Practice Address - Country:US
Practice Address - Phone:208-890-3787
Practice Address - Fax:208-350-4379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-5105101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty