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Provider Demographic Information - EVERGREEN ELM INC

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PROVIDER DEMOGRAPHIC INFORMATION Supporting line for group header


Name:	EVERGREEN ELM INC
Address:	50 MAIN ST BRADFORD, PA 16701-6516
Phone:	(814) 362-6853
Fax:	(814) 362-1048
E-mail:	LSTRUMBULL@EVERGREENELM.ORG
Web Site:	N/A

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PROVIDER CERTIFICATION INFORMATION Supporting line for group header

Click here to view Provider Certification Information

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PROVIDER'S PARENT/ REGIONAL OFFICE Supporting line for group header


Type:	Corporate Office
Name:	EVERGREEN ELM INC.
Address:	125 MAIN ST RM 400 BRADFORD, PA 16701-2085
Phone:	(814) 362-6853
Fax:	(814) 368-1048


Type:	Regional/Field Office	Counties Served:
Name:	EVERGREEN ELM INC.
Address:	147 ELM ST BRADFORD, PA 16701-2113
Phone:	(814) 362-6889
Fax:	(814) 362-1048


Type:	Regional/Field Office	Counties Served:
Name:	EVERGREEN ELM INC.
Address:	72 JACKSON AVE BRADFORD, PA 16701-1277
Phone:	(814) 362-6751
Fax:	(814) 362-1048


Type:	Regional/Field Office	Counties Served:
Name:	EVERGREEN ELM INC.
Address:	59 W CORYDON ST BRADFORD, PA 16701-2235
Phone:	(814) 362-4548
Fax:	(814) 362-1048


Type:	Regional/Field Office	Counties Served:
Name:	EVERGREEN ELM INC.
Address:	8 FORMAN ST BRADFORD, PA 16701-1240
Phone:	(814) 368-3586
Fax:	(814) 362-1048


Type:	Regional/Field Office	Counties Served:
Name:	EVERGREEN ELM INC.
Address:	8 ELM ST BRADFORD, PA 16701-2239
Phone:	(814) 368-3632
Fax:	(814) 362-1048


Type:	Regional/Field Office	Counties Served:
Name:	EVERGREEN ELM INC.
Address:	207 JACKSON AVE BRADFORD, PA 16701-1319
Phone:	(814) 368-7577
Fax:	(814) 362-1048


Type:	Regional/Field Office	Counties Served:
Name:	EVERGREEN ELM INC.
Address:	788 W WASHINGTON ST BRADFORD, PA 16701-2636
Phone:	(814) 368-9969
Fax:	(814) 362-1048


Type:	Regional/Field Office	Counties Served:
Name:	EVERGREEN ELM INC.
Address:	1283 SOUTH AVE BRADFORD, PA 16701-3838
Phone:	(814) 368-9134
Fax:	(814) 362-1048


Type:	Regional/Field Office	Counties Served:	McKean
Name:	EVERGREEN ELM INC.
Address:	50 MAIN ST BRADFORD, PA 16701-6516
Phone:	(814) 362-6853
Fax:	(814) 362-1048


Type:	Regional/Field Office	Counties Served:
Name:	EVERGREEN ELM INC.
Address:	28 SCHOOL ST BRADFORD, PA 16701-1257
Phone:	(814) 368-6456
Fax:	(814) 362-1048


Type:	Regional/Field Office	Counties Served:
Name:	EVERGREEN ELM INC.
Address:	10 FORMAN ST BRADFORD, PA 16701-1240
Phone:	(814) 368-4312
Fax:	(814) 362-1048

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PROVIDER SERVICES AND RATES Supporting line for group header


County : Cameron/Elk
\|Service Name / Level	\|Rate

In-Home & Commnty Supprts (Lvl 2)	$10.28 / 15 min.
Res Hab-3 Person-NG 1-Elig	$387.76 / 1 Day
Res Hab-3 Person-NG 1-Elig-w/Day Supports	$294.49 / 1 Day
Res Hab-3 Person-NG 2-Elig	$441.87 / 1 Day
Res Hab-3 Person-NG 2-Elig-w/Day Supports	$341.21 / 1 Day
Res Hab-3 Person-NG 3-Elig	$514.20 / 1 Day
Res Hab-3 Person-NG 3-Elig-w/Day Supports	$440.90 / 1 Day
Res Hab-3 Person-NG 4-Elig	$624.74 / 1 Day
Res Hab-3 Person-NG 4-Elig-w/Day Supports	$484.03 / 1 Day
Res Hab-4 Person-NG 1-Elig-w/Day Supports	$232.07 / 1 Day
Res Hab-4 Person-NG 2-Elig-w/Day Supports	$268.22 / 1 Day
Res Hab-4 Person-NG 3-Elig-w/Day Supports	$341.91 / 1 Day
Res Hab-4 Person-NG 4-Elig-w/Day Supports	$376.12 / 1 Day
Res Hab-5-8 Person-NG 1-Elig	$267.15 / 1 Day
Res Hab-5-8 Person-NG 1-Elig-w/Day Supports	$212.03 / 1 Day
Res Hab-5-8 Person-NG 2-Elig	$311.99 / 1 Day
Res Hab-5-8 Person-NG 2-Elig-w/Day Supports	$250.71 / 1 Day
Res Hab-5-8 Person-NG 3-Elig	$360.24 / 1 Day
Res Hab-5-8 Person-NG 3-Elig-w/Day Supports	$314.42 / 1 Day
Res Hab-5-8 Person-NG 4-Elig	$429.04 / 1 Day
Res Hab-5-8 Person-NG 4-Elig-w/Day Supports	$338.58 / 1 Day
Res Hab-Lic-3 Person-Inelig	$33.46 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 1	$304.14 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 2	$347.00 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 3	$401.47 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 4	$481.66 / 1 Day
Res Hab-Lic-4 Person-Inelig	$25.61 / 1 Day
Res Hab-Lic-5-8 Person-Inelig	$17.86 / 1 Day
Resid Hab-Unlic 1-Indiv Home (Eligible)	$132.49 / 1 Day
Resid Hab-Unlic 1-Indiv Home (Inelig)	$23.74 / 1 Day
Supplemental Habilitation 1:1 - 15 min	$5.77 / 15 min.

County : Erie
\|Service Name / Level	\|Rate

In-Home & Commnty Supprts (Lvl 2)	$10.28 / 15 min.

County : McKean
\|Service Name / Level	\|Rate

In-Home & Commnty Supprts (Lvl 2)	$10.28 / 15 min.
Life Sharing-1 person-Elig-NG 1 > 30 Hrs	$171.35 / 1 Day
Life Sharing-1 person-Elig-NG 2 > 30 Hrs	$204.29 / 1 Day
Life Sharing-1 person-Elig-NG 3 > 30 Hrs	$279.58 / 1 Day
Life Sharing-1 person-Elig-NG 4 > 30 Hrs	$355.61 / 1 Day
Res Hab-3 Person-NG 1-Elig	$387.76 / 1 Day
Res Hab-3 Person-NG 1-Elig-w/Day Supports	$294.49 / 1 Day
Res Hab-3 Person-NG 2-Elig	$441.87 / 1 Day
Res Hab-3 Person-NG 2-Elig-w/Day Supports	$341.21 / 1 Day
Res Hab-3 Person-NG 3-Elig	$514.20 / 1 Day
Res Hab-3 Person-NG 3-Elig-w/Day Supports	$440.90 / 1 Day
Res Hab-3 Person-NG 4-Elig	$624.74 / 1 Day
Res Hab-3 Person-NG 4-Elig-w/Day Supports	$484.03 / 1 Day
Res Hab-4 Person-NG 1-Elig-w/Day Supports	$232.07 / 1 Day
Res Hab-4 Person-NG 2-Elig-w/Day Supports	$268.22 / 1 Day
Res Hab-4 Person-NG 3-Elig-w/Day Supports	$341.91 / 1 Day
Res Hab-4 Person-NG 4-Elig-w/Day Supports	$376.12 / 1 Day
Res Hab-5-8 Person-NG 1-Elig	$267.15 / 1 Day
Res Hab-5-8 Person-NG 1-Elig-w/Day Supports	$212.03 / 1 Day
Res Hab-5-8 Person-NG 2-Elig	$311.99 / 1 Day
Res Hab-5-8 Person-NG 2-Elig-w/Day Supports	$250.71 / 1 Day
Res Hab-5-8 Person-NG 3-Elig	$360.24 / 1 Day
Res Hab-5-8 Person-NG 3-Elig-w/Day Supports	$314.42 / 1 Day
Res Hab-5-8 Person-NG 4-Elig	$429.04 / 1 Day
Res Hab-5-8 Person-NG 4-Elig-w/Day Supports	$338.58 / 1 Day
Res Hab-Lic-3 Person-Inelig	$33.46 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 1	$304.14 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 2	$347.00 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 3	$401.47 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 4	$481.66 / 1 Day
Res Hab-Lic-4 Person-Inelig	$25.61 / 1 Day
Res Hab-Lic-5-8 Person-Inelig	$17.86 / 1 Day
Resid Hab-Unlic 1-Indiv Home (Eligible)	$132.49 / 1 Day
Resid Hab-Unlic 1-Indiv Home (Inelig)	$23.74 / 1 Day
Respite-Lic-Day-1 person-NG 3	$855.36 / 1 Day
Respite-Lic-Day-1 person-NG 3-Emergency	$855.36 / 1 Day
Respite-Lic-Day-1 person-NG 4	$931.37 / 1 Day
Respite-Lic-Day-1 person-NG 4-Emergency	$931.37 / 1 Day
Respite-Lic-Day-2 person-NG 3	$696.86 / 1 Day
Respite-Lic-Day-2 person-NG 3-Emergency	$696.86 / 1 Day
Respite-Lic-Day-2 person-NG 4	$755.65 / 1 Day
Respite-Lic-Day-2 person-NG 4-Emergency	$755.65 / 1 Day
Respite-Lic-Day-3 person-NG 1	$348.80 / 1 Day
Respite-Lic-Day-3 person-NG 1-Emergency	$348.80 / 1 Day
Respite-Lic-Day-3 person-NG 2	$395.52 / 1 Day
Respite-Lic-Day-3 person-NG 2-Emergency	$395.52 / 1 Day
Respite-Lic-Day-3 person-NG 3	$495.21 / 1 Day
Respite-Lic-Day-3 person-NG 3-Emergency	$495.21 / 1 Day
Respite-Lic-Day-3 person-NG 4	$538.34 / 1 Day
Respite-Lic-Day-3 person-NG 4-Emergency	$538.34 / 1 Day
Respite-Lic-Day-4 person-NG 1	$278.56 / 1 Day
Respite-Lic-Day-4 person-NG 1-Emergency	$278.56 / 1 Day
Respite-Lic-Day-4 person-NG 2	$314.71 / 1 Day
Respite-Lic-Day-4 person-NG 2-Emergency	$314.71 / 1 Day
Respite-Lic-Day-4 person-NG 3	$388.40 / 1 Day
Respite-Lic-Day-4 person-NG 3-Emergency	$388.40 / 1 Day
Respite-Lic-Day-4 person-NG 4	$422.61 / 1 Day
Respite-Lic-Day-4 person-NG 4-Emergency	$422.61 / 1 Day
Respite-Unlic-Day (Basic 1:4) In-Home	$90.59 / 1 Day
Respite-Unlic-Day (Basic 1:4) Out-of-Home	$90.59 / 1 Day
Respite-Unlic-Day (Level 1, 1:3) In-Home	$119.11 / 1 Day
Respite-Unlic-Day (Level 1, 1:3) Out-of-Home	$119.11 / 1 Day
Respite-Unlic-Day (Level 2, 1:2) In-Home	$176.17 / 1 Day
Respite-Unlic-Day (Level 2, 1:2) Out-of-Home	$176.17 / 1 Day
Supplemental Habilitation 1:1 - 15 min	$5.77 / 15 min.

County : Potter
\|Service Name / Level	\|Rate

Res Hab-3 Person-NG 1-Elig	$387.76 / 1 Day
Res Hab-3 Person-NG 1-Elig-w/Day Supports	$294.49 / 1 Day
Res Hab-3 Person-NG 2-Elig	$441.87 / 1 Day
Res Hab-3 Person-NG 2-Elig-w/Day Supports	$341.21 / 1 Day
Res Hab-3 Person-NG 3-Elig	$514.20 / 1 Day
Res Hab-3 Person-NG 3-Elig-w/Day Supports	$440.90 / 1 Day
Res Hab-3 Person-NG 4-Elig	$624.74 / 1 Day
Res Hab-3 Person-NG 4-Elig-w/Day Supports	$484.03 / 1 Day
Res Hab-4 Person-NG 1-Elig-w/Day Supports	$232.07 / 1 Day
Res Hab-4 Person-NG 2-Elig-w/Day Supports	$268.22 / 1 Day
Res Hab-4 Person-NG 3-Elig-w/Day Supports	$341.91 / 1 Day
Res Hab-4 Person-NG 4-Elig-w/Day Supports	$376.12 / 1 Day
Res Hab-5-8 Person-NG 1-Elig	$267.15 / 1 Day
Res Hab-5-8 Person-NG 1-Elig-w/Day Supports	$212.03 / 1 Day
Res Hab-5-8 Person-NG 2-Elig	$311.99 / 1 Day
Res Hab-5-8 Person-NG 2-Elig-w/Day Supports	$250.71 / 1 Day
Res Hab-5-8 Person-NG 3-Elig	$360.24 / 1 Day
Res Hab-5-8 Person-NG 3-Elig-w/Day Supports	$314.42 / 1 Day
Res Hab-5-8 Person-NG 4-Elig	$429.04 / 1 Day
Res Hab-5-8 Person-NG 4-Elig-w/Day Supports	$338.58 / 1 Day
Res Hab-Lic-3 Person-Inelig	$33.46 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 1	$304.14 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 2	$347.00 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 3	$401.47 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 4	$481.66 / 1 Day
Res Hab-Lic-4 Person-Inelig	$25.61 / 1 Day
Res Hab-Lic-5-8 Person-Inelig	$17.86 / 1 Day
Resid Hab-Unlic 1-Indiv Home (Eligible)	$132.49 / 1 Day
Resid Hab-Unlic 1-Indiv Home (Inelig)	$23.74 / 1 Day
Respite-Unlic-Day (Basic 1:4) Out-of-Home	$90.59 / 1 Day
Respite-Unlic-Day (Level 1, 1:3) Out-of-Home	$119.11 / 1 Day
Respite-Unlic-Day (Level 2, 1:2) Out-of-Home	$176.17 / 1 Day
Supplemental Habilitation 1:1 - 15 min	$5.77 / 15 min.

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