Provider Demographics
NPI:1174754071
Name:EVERGREEN COUNSELING SERVICES, PC
Entity type:Organization
Organization Name:EVERGREEN COUNSELING SERVICES, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:WOTRING
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:360-694-3040
Mailing Address - Street 1:1104 MAIN ST
Mailing Address - Street 2:SUITE #440
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-2999
Mailing Address - Country:US
Mailing Address - Phone:360-694-3040
Mailing Address - Fax:360-735-7484
Practice Address - Street 1:1104 MAIN ST
Practice Address - Street 2:SUITE #440
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-2999
Practice Address - Country:US
Practice Address - Phone:360-694-3040
Practice Address - Fax:360-735-7484
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-27
Last Update Date:2009-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORL08951041C0700X
WALW000050791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty