Provider Demographics
NPI:1841046364
Name:EVERGREEN THERAPY SERVICES
Entity type:Organization
Organization Name:EVERGREEN THERAPY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JAKOB
Authorized Official - Middle Name:
Authorized Official - Last Name:MAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DSW, LCSW
Authorized Official - Phone:702-859-1097
Mailing Address - Street 1:6909 GRACEFUL CLOUD AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89011-4980
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1070 W HORIZON RIDGE PKWY STE 210
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89012-6020
Practice Address - Country:US
Practice Address - Phone:406-396-5168
Practice Address - Fax:702-405-0924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health