Provider Demographics
NPI:1558652933
Name:EVERETTS, CONNI3 LOU (LCSWR)
Entity Type:Individual
Prefix:MS
First Name:CONNI3
Middle Name:LOU
Last Name:EVERETTS
Suffix:
Gender:F
Credentials:LCSWR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-3804
Mailing Address - Country:US
Mailing Address - Phone:315-272-2600
Mailing Address - Fax:315-733-8169
Practice Address - Street 1:628 MARY ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-2419
Practice Address - Country:US
Practice Address - Phone:315-272-2700
Practice Address - Fax:315-732-2229
Is Sole Proprietor?:No
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0458171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical