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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: 50 MAIN ST
BRADFORD, PA 16701-6516
Phone: (814) 362-6853
Fax: (814) 368-1048
 
 
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: 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: 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: 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: 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: 1283 SOUTH AVE
BRADFORD, PA 16701-3838
Phone: (814) 368-9134
Fax: (814) 362-1048
 
 
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: 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) $11.10 / 15 min.
Res Hab-2 Person-NG 1-Elig $554.38 / 1 Day
Res Hab-2 Person-NG 1-Elig-w/Day Supports $433.05 / 1 Day
Res Hab-2 Person-NG 2-Elig $643.34 / 1 Day
Res Hab-2 Person-NG 2-Elig-w/Day Supports $545.91 / 1 Day
Res Hab-2 Person-NG 3-Elig $726.82 / 1 Day
Res Hab-2 Person-NG 3-Elig-w/Day Supports $668.54 / 1 Day
Res Hab-2 Person-NG 4-Elig $869.36 / 1 Day
Res Hab-2 Person-NG 4-Elig-w/Day Supports $730.86 / 1 Day
Res Hab-2 Person-NG5-Elig $1,312.57 / 1 Day
Res Hab-2 Person-NG5-Elig-w/Day Supports $1,215.16 / 1 Day
Res Hab-3 Person-NG 1-Elig $411.03 / 1 Day
Res Hab-3 Person-NG 1-Elig-w/Day Supports $312.16 / 1 Day
Res Hab-3 Person-NG 2-Elig $468.38 / 1 Day
Res Hab-3 Person-NG 2-Elig-w/Day Supports $361.68 / 1 Day
Res Hab-3 Person-NG 3-Elig $545.05 / 1 Day
Res Hab-3 Person-NG 3-Elig-w/Day Supports $467.35 / 1 Day
Res Hab-3 Person-NG 4-Elig $662.22 / 1 Day
Res Hab-3 Person-NG 4-Elig-w/Day Supports $513.07 / 1 Day
Res Hab-3 Person-NG5-Elig $1,004.32 / 1 Day
Res Hab-3 Person-NG5-Elig-w/Day Supports $835.46 / 1 Day
Res Hab-4 Person-NG 1-Elig-w/Day Supports $245.99 / 1 Day
Res Hab-4 Person-NG 2-Elig-w/Day Supports $284.31 / 1 Day
Res Hab-4 Person-NG 3-Elig-w/Day Supports $362.42 / 1 Day
Res Hab-4 Person-NG 4-Elig-w/Day Supports $398.69 / 1 Day
Res Hab-5-8 Person-NG 1-Elig $283.18 / 1 Day
Res Hab-5-8 Person-NG 1-Elig-w/Day Supports $224.75 / 1 Day
Res Hab-5-8 Person-NG 2-Elig $330.71 / 1 Day
Res Hab-5-8 Person-NG 2-Elig-w/Day Supports $265.75 / 1 Day
Res Hab-5-8 Person-NG 3-Elig $381.85 / 1 Day
Res Hab-5-8 Person-NG 3-Elig-w/Day Supports $333.29 / 1 Day
Res Hab-5-8 Person-NG 4-Elig $454.78 / 1 Day
Res Hab-5-8 Person-NG 4-Elig-w/Day Supports $358.89 / 1 Day
Res Hab-Lic-2 Person-Inelig $50.22 / 1 Day
Res Hab-Lic-3 Person-Inelig $35.47 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 1 $322.49 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 2 $367.82 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 3 $425.56 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 4 $510.56 / 1 Day
Res Hab-Lic-4 Person-Inelig $27.15 / 1 Day
Res Hab-Lic-5-8 Person-Inelig $18.93 / 1 Day
Resid Hab-Unlic 1-Indiv Home (Eligible) $140.44 / 1 Day
Resid Hab-Unlic 1-Indiv Home (Inelig) $25.16 / 1 Day
Supplemental Habilitation 1:1 - 15 min $6.12 / 15 min.
 
County : Erie
|Service Name / Level |Rate
In-Home & Commnty Supprts (Lvl 2) $11.10 / 15 min.
 
County : McKean
|Service Name / Level |Rate
In-Home & Commnty Supprts (Lvl 2) $11.10 / 15 min.
Life Sharing-1 Person-Elig-NG 1-by Relative >30Hrs $181.63 / 1 Day
Life Sharing-1 Person-NG1-Relative >30Hrs WithOut $200.90 / 1 Day
Res Hab-2 Person-NG 1-Elig $554.38 / 1 Day
Res Hab-2 Person-NG 1-Elig-w/Day Supports $433.05 / 1 Day
Res Hab-2 Person-NG 2-Elig $643.34 / 1 Day
Res Hab-2 Person-NG 2-Elig-w/Day Supports $545.91 / 1 Day
Res Hab-2 Person-NG 3-Elig $726.82 / 1 Day
Res Hab-2 Person-NG 3-Elig-w/Day Supports $668.54 / 1 Day
Res Hab-2 Person-NG 4-Elig $869.36 / 1 Day
Res Hab-2 Person-NG 4-Elig-w/Day Supports $730.86 / 1 Day
Res Hab-2 Person-NG5-Elig $1,312.57 / 1 Day
Res Hab-2 Person-NG5-Elig-w/Day Supports $1,215.16 / 1 Day
Res Hab-3 Person-NG 1-Elig $411.03 / 1 Day
Res Hab-3 Person-NG 1-Elig-w/Day Supports $312.16 / 1 Day
Res Hab-3 Person-NG 2-Elig $468.38 / 1 Day
Res Hab-3 Person-NG 2-Elig-w/Day Supports $361.68 / 1 Day
Res Hab-3 Person-NG 3-Elig $545.05 / 1 Day
Res Hab-3 Person-NG 3-Elig-w/Day Supports $467.35 / 1 Day
Res Hab-3 Person-NG 4-Elig $662.22 / 1 Day
Res Hab-3 Person-NG 4-Elig-w/Day Supports $513.07 / 1 Day
Res Hab-3 Person-NG5-Elig $1,004.32 / 1 Day
Res Hab-3 Person-NG5-Elig-w/Day Supports $835.46 / 1 Day
Res Hab-4 Person-NG 1-Elig-w/Day Supports $245.99 / 1 Day
Res Hab-4 Person-NG 2-Elig-w/Day Supports $284.31 / 1 Day
Res Hab-4 Person-NG 3-Elig-w/Day Supports $362.42 / 1 Day
Res Hab-4 Person-NG 4-Elig-w/Day Supports $398.69 / 1 Day
Res Hab-4 Person-NG5-Elig-w/Day Supports $642.84 / 1 Day
Res Hab-5-8 Person-NG 1-Elig $283.18 / 1 Day
Res Hab-5-8 Person-NG 1-Elig-w/Day Supports $224.75 / 1 Day
Res Hab-5-8 Person-NG 2-Elig $330.71 / 1 Day
Res Hab-5-8 Person-NG 2-Elig-w/Day Supports $265.75 / 1 Day
Res Hab-5-8 Person-NG 3-Elig $381.85 / 1 Day
Res Hab-5-8 Person-NG 3-Elig-w/Day Supports $333.29 / 1 Day
Res Hab-5-8 Person-NG 4-Elig $454.78 / 1 Day
Res Hab-5-8 Person-NG 4-Elig-w/Day Supports $358.89 / 1 Day
Res Hab-Lic-2 Person-Inelig $50.22 / 1 Day
Res Hab-Lic-3 Person-Inelig $35.47 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 1 $322.49 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 2 $367.82 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 3 $425.56 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 4 $510.56 / 1 Day
Res Hab-Lic-4 Person-Elig-NG5 $766.28 / 1 Day
Res Hab-Lic-4 Person-Inelig $27.15 / 1 Day
Res Hab-Lic-5-8 Person-Inelig $18.93 / 1 Day
Resid Hab-Unlic 1-Indiv Home (Eligible) $140.44 / 1 Day
Resid Hab-Unlic 1-Indiv Home (Inelig) $25.16 / 1 Day
Respite Base-Emerg Lic 6400 24 Hrs Lvl 2 Enh-TD U2 Not Set
Respite Base-Emerg Lic 6400 24 Hrs Lvl 2 Enh-TE U2 Not Set
Respite, Base-Emerg Licen 6400 24 Hrs Lvl 2 Enh-U2 Not Set
Respite, Base-Emerg Licen 6400 24 Hrs Lvl 2-U2 Not Set
Respite-Base Out-of-Home 24 Hours (Level 2 Enh) Not Set
Respite-Base Out-of-Home 24 Hours (Level 2 Enh)-TD Not Set
Respite-Base Out-of-Home 24 Hours (Level 2 Enh)-TE Not Set
Respite-Base Out-of-Home 24 Hours (Level 2)-Day Not Set
Respite-Lic-Day-2 person-NG 2 $616.04 / 1 Day
Respite-Lic-Day-3 person-NG 1 $369.73 / 1 Day
Respite-Lic-Day-3 person-NG 1-Emergency $369.73 / 1 Day
Respite-Lic-Day-3 person-NG 2 $419.25 / 1 Day
Respite-Lic-Day-3 person-NG 2-Emergency $419.25 / 1 Day
Respite-Lic-Day-3 person-NG 3 $524.92 / 1 Day
Respite-Lic-Day-3 person-NG 3-Emergency $524.92 / 1 Day
Respite-Lic-Day-3 person-NG 4 $570.64 / 1 Day
Respite-Lic-Day-3 person-NG 4-Emergency $570.64 / 1 Day
Respite-Lic-Day-4 person-NG 1 $295.27 / 1 Day
Respite-Lic-Day-4 person-NG 1-Emergency $295.27 / 1 Day
Respite-Lic-Day-4 person-NG 2 $333.59 / 1 Day
Respite-Lic-Day-4 person-NG 2-ECS Not Set
Respite-Lic-Day-4 person-NG 2-Emergency $333.59 / 1 Day
Respite-Lic-Day-4 person-NG 2-Emergency-ECS Not Set
Respite-Lic-Day-4 person-NG 3 $411.70 / 1 Day
Respite-Lic-Day-4 person-NG 3-Emergency $411.70 / 1 Day
Respite-Lic-Day-4 person-NG 4 $447.97 / 1 Day
Respite-Lic-Day-4 person-NG 4-Emergency $447.97 / 1 Day
Respite-Unlic-Day (Basic 1:4) Out-of-Home $97.84 / 1 Day
Respite-Unlic-Day (Level 1, 1:3) Out-of-Home $128.64 / 1 Day
Respite-Unlic-Day (Level 2, 1:2) Out-of-Home $190.26 / 1 Day
Supplemental Habilitation 1:1 - 15 min $6.12 / 15 min.
Supported Living-1 Person-NG1 $160.19 / 1 Day
Supported Living-1 Person-NG2 $268.46 / 1 Day
Supported Living-1 Person-NG3 $428.64 / 1 Day
Supported Living-1 Person-NG4 $576.34 / 1 Day
Supported Living-1 Person-NG5 $576.34 / 1 Day
 
County : Potter
|Service Name / Level |Rate
Res Hab-3 Person-NG 1-Elig $411.03 / 1 Day
Res Hab-3 Person-NG 1-Elig-w/Day Supports $312.16 / 1 Day
Res Hab-3 Person-NG 2-Elig $468.38 / 1 Day
Res Hab-3 Person-NG 2-Elig-w/Day Supports $361.68 / 1 Day
Res Hab-3 Person-NG 3-Elig $545.05 / 1 Day
Res Hab-3 Person-NG 3-Elig-w/Day Supports $467.35 / 1 Day
Res Hab-3 Person-NG 4-Elig $662.22 / 1 Day
Res Hab-3 Person-NG 4-Elig-w/Day Supports $513.07 / 1 Day
Res Hab-4 Person-NG 1-Elig-w/Day Supports $245.99 / 1 Day
Res Hab-4 Person-NG 2-Elig-w/Day Supports $284.31 / 1 Day
Res Hab-4 Person-NG 3-Elig-w/Day Supports $362.42 / 1 Day
Res Hab-4 Person-NG 4-Elig-w/Day Supports $398.69 / 1 Day
Res Hab-5-8 Person-NG 1-Elig $283.18 / 1 Day
Res Hab-5-8 Person-NG 1-Elig-w/Day Supports $224.75 / 1 Day
Res Hab-5-8 Person-NG 2-Elig $330.71 / 1 Day
Res Hab-5-8 Person-NG 2-Elig-w/Day Supports $265.75 / 1 Day
Res Hab-5-8 Person-NG 3-Elig $381.85 / 1 Day
Res Hab-5-8 Person-NG 3-Elig-w/Day Supports $333.29 / 1 Day
Res Hab-5-8 Person-NG 4-Elig $454.78 / 1 Day
Res Hab-5-8 Person-NG 4-Elig-w/Day Supports $358.89 / 1 Day
Res Hab-Lic-3 Person-Inelig $35.47 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 1 $322.49 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 2 $367.82 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 3 $425.56 / 1 Day
Res Hab-Lic-4 Person-Elig-NG 4 $510.56 / 1 Day
Res Hab-Lic-4 Person-Inelig $27.15 / 1 Day
Res Hab-Lic-5-8 Person-Inelig $18.93 / 1 Day
Resid Hab-Unlic 1-Indiv Home (Eligible) $140.44 / 1 Day
Resid Hab-Unlic 1-Indiv Home (Inelig) $25.16 / 1 Day
Respite-Unlic-Day (Basic 1:4) Out-of-Home $97.84 / 1 Day
Respite-Unlic-Day (Level 1, 1:3) Out-of-Home $128.64 / 1 Day
Respite-Unlic-Day (Level 2, 1:2) Out-of-Home $190.26 / 1 Day
Supplemental Habilitation 1:1 - 15 min $6.12 / 15 min.

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