Provider Demographics
NPI:1154412492
Name:EVERGREEN BEHAVIORAL HEALTH CENTER, INC.
Entity type:Organization
Organization Name:EVERGREEN BEHAVIORAL HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:B.
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:FETTY
Authorized Official - Suffix:
Authorized Official - Credentials:AB
Authorized Official - Phone:304-455-4415
Mailing Address - Street 1:240 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:NEW MARTINSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26155-1771
Mailing Address - Country:US
Mailing Address - Phone:304-455-4415
Mailing Address - Fax:304-455-2501
Practice Address - Street 1:240 NORTH ST
Practice Address - Street 2:
Practice Address - City:NEW MARTINSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26155-1771
Practice Address - Country:US
Practice Address - Phone:304-455-4415
Practice Address - Fax:304-455-2501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV112251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0005321000Medicaid
WV0005321002Medicaid
WV0005321001Medicaid