Provider Demographics
NPI:1932814662
Name:EVERGREEN THERAPY LLC
Entity Type:Organization
Organization Name:EVERGREEN THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONAE
Authorized Official - Middle Name:N
Authorized Official - Last Name:CUNNINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:LIMHP
Authorized Official - Phone:402-401-7560
Mailing Address - Street 1:6601 S 70TH ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516-3602
Mailing Address - Country:US
Mailing Address - Phone:402-401-7560
Mailing Address - Fax:
Practice Address - Street 1:6601 S 70TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516-3602
Practice Address - Country:US
Practice Address - Phone:402-401-7560
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-17
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty