Provider Demographics
NPI:1124767587
Name:EVERGREEN SUPPORTED LIVING
Entity type:Organization
Organization Name:EVERGREEN SUPPORTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ZAY
Authorized Official - Middle Name:AIDAN SMITH
Authorized Official - Last Name:MCSHANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-671-5898
Mailing Address - Street 1:305 FLORA ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4430
Mailing Address - Country:US
Mailing Address - Phone:360-671-5898
Mailing Address - Fax:360-922-0648
Practice Address - Street 1:305 FLORA ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98225-4430
Practice Address - Country:US
Practice Address - Phone:360-671-5898
Practice Address - Fax:360-922-0648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental DisabilitiesGroup - Multi-Specialty
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty