Provider Demographics
NPI:1629242219
Name:EVERETTE, SAMUEL WADE
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:WADE
Last Name:EVERETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 411
Mailing Address - Street 2:JOHNSTON COUNTY MENTAL HEALTH CENTER
Mailing Address - City:SMITHFIELD
Mailing Address - State:NC
Mailing Address - Zip Code:27577-0411
Mailing Address - Country:US
Mailing Address - Phone:919-989-5500
Mailing Address - Fax:919-989-5532
Practice Address - Street 1:521 N BRIGHTLEAF BLVD
Practice Address - Street 2:JOHNSTON COUNTY MENTAL HEALTH CENTER
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577-4407
Practice Address - Country:US
Practice Address - Phone:919-989-5500
Practice Address - Fax:919-989-5532
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0041951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical