Provider Demographics
NPI:1285496968
Name:EVERGREEN SPEECH THERAPY
Entity type:Organization
Organization Name:EVERGREEN SPEECH THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BLYTHE
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAPER
Authorized Official - Suffix:
Authorized Official - Credentials:MA-CCC-SLP
Authorized Official - Phone:732-735-1969
Mailing Address - Street 1:1014 CALVIN ST
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-1056
Mailing Address - Country:US
Mailing Address - Phone:732-735-1969
Mailing Address - Fax:
Practice Address - Street 1:1014 CALVIN ST
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-1056
Practice Address - Country:US
Practice Address - Phone:732-735-1969
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-29
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty