Provider Demographics
NPI:1114754066
Name:EVERGREEN PHYSIATRY, PLLC
Entity type:Organization
Organization Name:EVERGREEN PHYSIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:ABRAHAM
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:832-856-0412
Mailing Address - Street 1:2637 N 400 E STE 164
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-2240
Mailing Address - Country:US
Mailing Address - Phone:214-970-6817
Mailing Address - Fax:844-803-4513
Practice Address - Street 1:13031 WORTHAM CENTER DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77065-5662
Practice Address - Country:US
Practice Address - Phone:832-280-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-16
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty