Provider Demographics
NPI:1255717385
Name:EVERETT, TYSON (CSAC)
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:EVERETT
Suffix:
Gender:M
Credentials:CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 S INDIANA AVE BSMT
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637-1011
Mailing Address - Country:US
Mailing Address - Phone:773-488-9460
Mailing Address - Fax:773-488-9462
Practice Address - Street 1:5500 S INDIANA AVE BSMT
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1011
Practice Address - Country:US
Practice Address - Phone:773-488-9460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILA-3249-0001251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No251B00000XAgenciesCase Management