Provider Demographics
NPI:1487129284
Name:EVERGROW COUNSELING LLC
Entity type:Organization
Organization Name:EVERGROW COUNSELING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH CLINICIAN
Authorized Official - Prefix:MS
Authorized Official - First Name:JALEESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, NCC
Authorized Official - Phone:203-927-6409
Mailing Address - Street 1:843 MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-6041
Mailing Address - Country:US
Mailing Address - Phone:203-927-6409
Mailing Address - Fax:
Practice Address - Street 1:843 MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-6041
Practice Address - Country:US
Practice Address - Phone:203-927-6409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-08
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1891038956Medicaid