Provider Demographics
NPI:1992152821
Name:EVERGREEN RECOVERY
Entity type:Organization
Organization Name:EVERGREEN RECOVERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BACKUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:651-252-6070
Mailing Address - Street 1:1400 ENERGY PARK DR
Mailing Address - Street 2:SUITE 21
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-5272
Mailing Address - Country:US
Mailing Address - Phone:651-252-6070
Mailing Address - Fax:651-252-6071
Practice Address - Street 1:1400 ENERGY PARK DR
Practice Address - Street 2:SUITE 21
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-5272
Practice Address - Country:US
Practice Address - Phone:651-252-6070
Practice Address - Fax:651-252-6071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-20
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303683101YA0400X
MN303672101YA0400X
MN304003101YA0400X
MN1204101YP2500X
261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty