Provider Demographics
NPI:1790355477
Name:EVERETT, MIMIR JOTTUN (MS, LCSW)
Entity type:Individual
Prefix:
First Name:MIMIR
Middle Name:JOTTUN
Last Name:EVERETT
Suffix:
Gender:
Credentials:MS, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 RIO GRANDE BLVD NW STE G252
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87104-2050
Mailing Address - Country:US
Mailing Address - Phone:505-720-8112
Mailing Address - Fax:
Practice Address - Street 1:901 RIO GRANDE BLVD NW STE G252
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87104-2050
Practice Address - Country:US
Practice Address - Phone:505-702-8112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-25
Last Update Date:2025-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND266421041C0700X
NMC-117841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical