Provider Demographics
NPI:1932368628
Name:EVERGREEN PSYCHOLOGY, LLC
Entity Type:Organization
Organization Name:EVERGREEN PSYCHOLOGY, LLC
Other - Org Name:EVERGREEN PSYCHOLOGY AND PSYCHOTHERAPY ASSOCIATES, LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:F
Authorized Official - Last Name:MANNIS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:301-662-4160
Mailing Address - Street 1:235 W PATRICK ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-6934
Mailing Address - Country:US
Mailing Address - Phone:301-662-4160
Mailing Address - Fax:301-620-4344
Practice Address - Street 1:235 W PATRICK ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-6934
Practice Address - Country:US
Practice Address - Phone:301-662-4160
Practice Address - Fax:301-620-4344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty