Provider Demographics
NPI:1124101464
Name:EVERGREEN BEHAVIORAL SERVICES
Entity type:Organization
Organization Name:EVERGREEN BEHAVIORAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WELCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-778-0035
Mailing Address - Street 1:131 FRANKLIN HEALTH COMMONS
Mailing Address - Street 2:SUITE A
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938
Mailing Address - Country:US
Mailing Address - Phone:207-778-0035
Mailing Address - Fax:207-778-6879
Practice Address - Street 1:131 FRANKLIN HEALTH COMMONS
Practice Address - Street 2:SUITE A MT BLUE HEALTH CENTER
Practice Address - City:FARMINGTON
Practice Address - State:ME
Practice Address - Zip Code:04938
Practice Address - Country:US
Practice Address - Phone:207-778-0035
Practice Address - Fax:207-778-6879
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRANKLIN MEMORIAL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-23
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME221361261QR0405X
ME227282261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM6270Medicare ID - Type Unspecified