Provider Demographics
NPI:1639574015
Name:EVERSON, MICHAEL CHARLES (LMFT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CHARLES
Last Name:EVERSON
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8037 FAIR OAKS BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-6742
Mailing Address - Country:US
Mailing Address - Phone:916-905-3395
Mailing Address - Fax:
Practice Address - Street 1:8037 FAIR OAKS BLVD STE 110
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-6742
Practice Address - Country:US
Practice Address - Phone:916-905-3395
Practice Address - Fax:916-905-0315
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA81305106H00000X
CA97556106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA81305OtherMFT REGISTERED INTERN #
CA97556OtherLMFT