Provider Demographics
NPI:1558128553
Name:EVERGREEN ABA LLC
Entity type:Organization
Organization Name:EVERGREEN ABA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TALIA
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHUSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-410-9670
Mailing Address - Street 1:8130 BALSON AVE.
Mailing Address - Street 2:
Mailing Address - City:ST. LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63130
Mailing Address - Country:US
Mailing Address - Phone:314-410-9670
Mailing Address - Fax:855-611-8213
Practice Address - Street 1:900 SE 5TH STREET
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712
Practice Address - Country:US
Practice Address - Phone:314-410-9670
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LATITUDE ABA HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-05
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO730082591Medicaid