Provider Demographics
NPI:1073338067
Name:EVERGREEN CLINICAL SERVICES LLC
Entity type:Organization
Organization Name:EVERGREEN CLINICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:INGBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:917-868-6745
Mailing Address - Street 1:444 MANHATTAN AVE APT 6K
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-1068
Mailing Address - Country:US
Mailing Address - Phone:917-868-6745
Mailing Address - Fax:
Practice Address - Street 1:444 MANHATTAN AVE APT 6K
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-1068
Practice Address - Country:US
Practice Address - Phone:917-868-6745
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-15
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty