Provider Demographics
NPI:1184261588
Name:EVERETT, MARIE N
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:N
Last Name:EVERETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 TERRACE LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01118-1333
Mailing Address - Country:US
Mailing Address - Phone:617-872-1247
Mailing Address - Fax:
Practice Address - Street 1:300
Practice Address - Street 2:BIRNIE AVENUE
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107
Practice Address - Country:US
Practice Address - Phone:617-872-1247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4033224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant