Provider Demographics
NPI:1558172510
Name:EVERETT, ALISA
Entity type:Individual
Prefix:MR
First Name:ALISA
Middle Name:
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 1:65850 PIERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:DSRT HOT SPGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-3000
Mailing Address - Country:US
Mailing Address - Phone:760-288-7096
Mailing Address - Fax:
Practice Address - Street 1:65850 PIERSON BLVD
Practice Address - Street 2:
Practice Address - City:DSRT HOT SPGS
Practice Address - State:CA
Practice Address - Zip Code:92240-3000
Practice Address - Country:US
Practice Address - Phone:760-288-7096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YS0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool