Provider Demographics
NPI:1972659175
Name:EVERETT, ELISABETH G (LICSW)
Entity Type:Individual
Prefix:
First Name:ELISABETH
Middle Name:G
Last Name:EVERETT
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 MILL ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-4784
Mailing Address - Country:US
Mailing Address - Phone:781-643-1943
Mailing Address - Fax:
Practice Address - Street 1:22 MILL ST
Practice Address - Street 2:SUITE 105
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-4784
Practice Address - Country:US
Practice Address - Phone:781-643-1943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101046101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPO29OOMedicare ID - Type UnspecifiedMEDICARE AND BLUE SHIELD