Provider Demographics
NPI:1619050069
Name:EVERED, LAEEQ (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAEEQ
Middle Name:
Last Name:EVERED
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2728 DURANT AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94704-1725
Mailing Address - Country:US
Mailing Address - Phone:925-685-9463
Mailing Address - Fax:925-685-9682
Practice Address - Street 1:3050 CITRUS CIR
Practice Address - Street 2:STE 202
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2662
Practice Address - Country:US
Practice Address - Phone:925-685-9463
Practice Address - Fax:925-685-9682
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-21
Last Update Date:2016-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18494103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL184941Medicare ID - Type Unspecified