Provider Demographics
NPI:1285154054
Name:EVERGREEN COUNSELING LLC
Entity type:Organization
Organization Name:EVERGREEN COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROFT
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:208-525-2090
Mailing Address - Street 1:1601 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6313
Mailing Address - Country:US
Mailing Address - Phone:208-525-2090
Mailing Address - Fax:208-523-8978
Practice Address - Street 1:1920 E 17TH ST STE 240
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8036
Practice Address - Country:US
Practice Address - Phone:208-589-8690
Practice Address - Fax:208-523-8978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-2674101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty