Basic Information
| Provider Information | |||||||||
| NPI: | 1174754071 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERGREEN COUNSELING SERVICES, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | EVERGREEN COUNSELING SERVICES, PS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1104 MAIN ST | ||||||||
| Address2: | SUITE #440 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986602999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606943040 | ||||||||
| FaxNumber: | 3607357484 | ||||||||
| Practice Location | |||||||||
| Address1: | 1104 MAIN ST | ||||||||
| Address2: | SUITE #440 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986602999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606943040 | ||||||||
| FaxNumber: | 3607357484 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2009 | ||||||||
| LastUpdateDate: | 07/27/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WOTRING | ||||||||
| AuthorizedOfficialFirstName: | DALE | ||||||||
| AuthorizedOfficialMiddleName: | EDWARD | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3606943040 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | LICSW | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | L0895 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | LW00005079 | WA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.