Basic Information
| Provider Information | |||||||||
| NPI: | 1205146776 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EVERGREEN BEHAVIORAL HEALTH PC | ||||||||
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| OtherOrganizationName: | EVERGREEN BEHAVIORAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2621 NE 134TH ST STE 340 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986863036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604500140 | ||||||||
| FaxNumber: | 8773430535 | ||||||||
| Practice Location | |||||||||
| Address1: | 2621 NE 134TH ST STE 340 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986863036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604500140 | ||||||||
| FaxNumber: | 8773430535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2010 | ||||||||
| LastUpdateDate: | 10/21/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FANCHER | ||||||||
| AuthorizedOfficialFirstName: | JILL | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | CLINIC DIRECTOR/OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3604500140 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 225700000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist | 103TC0700X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.