Provider Demographics
NPI:1528217064
Name:EVERETT, MARY THERESE (MA)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:THERESE
Last Name:EVERETT
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9131 LIMA RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46818-1803
Mailing Address - Country:US
Mailing Address - Phone:260-489-2693
Mailing Address - Fax:260-489-1495
Practice Address - Street 1:9131 LIMA RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-1803
Practice Address - Country:US
Practice Address - Phone:260-489-2693
Practice Address - Fax:260-489-1495
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN23002170A231H00000X, 231HA2400X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology Practitioner
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter