Provider Demographics
NPI:1447314539
Name:THE EVERGREEN CLINIC
Entity type:Organization
Organization Name:THE EVERGREEN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:LMHC
Authorized Official - Phone:425-821-1810
Mailing Address - Street 1:12025 115TH AVE NE
Mailing Address - Street 2:#200
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034
Mailing Address - Country:US
Mailing Address - Phone:425-821-1810
Mailing Address - Fax:425-823-1231
Practice Address - Street 1:12025 115TH AVE NE
Practice Address - Street 2:#200
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034
Practice Address - Country:US
Practice Address - Phone:425-821-1810
Practice Address - Fax:425-823-1231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6018898162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty