Provider Demographics
NPI:1770328973
Name:EVEREST, SIMON
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:EVEREST
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:693 WESTERN AVE N APT 1
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-1568
Mailing Address - Country:US
Mailing Address - Phone:320-496-7301
Mailing Address - Fax:
Practice Address - Street 1:1032 GRAND AVE # 100
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3064
Practice Address - Country:US
Practice Address - Phone:320-496-7301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4416106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist