Provider Demographics
NPI:1083687107
Name:EVERETT, ALICIA MARIE (PT)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:EVERETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:792 N MAIN ST
Mailing Address - Street 2:STE 100C
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-1644
Mailing Address - Country:US
Mailing Address - Phone:315-458-2552
Mailing Address - Fax:315-458-2575
Practice Address - Street 1:792 N MAIN ST
Practice Address - Street 2:STE 100C
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-1644
Practice Address - Country:US
Practice Address - Phone:315-458-2552
Practice Address - Fax:315-458-2575
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207726225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA9327Medicare ID - Type Unspecified