Provider Demographics
NPI:1033830690
Name:EVERETT, KATISHA LASHAAN
Entity Type:Individual
Prefix:
First Name:KATISHA
Middle Name:LASHAAN
Last Name:EVERETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1677 VICKSBURG DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-5166
Mailing Address - Country:US
Mailing Address - Phone:707-398-7158
Mailing Address - Fax:
Practice Address - Street 1:1745 ENTERPRISE DRIVE
Practice Address - Street 2:BLDG 2, SUITE 1A
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533
Practice Address - Country:US
Practice Address - Phone:707-416-4836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1067611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical