Provider Demographics
NPI:1912133968
Name:EVERINGHAM, CARLY L
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:L
Last Name:EVERINGHAM
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 1:820 INNKEEPERS CT
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IN
Mailing Address - Zip Code:46793-9499
Mailing Address - Country:US
Mailing Address - Phone:574-528-0888
Mailing Address - Fax:
Practice Address - Street 1:820 INNKEEPERS CT
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IN
Practice Address - Zip Code:46793-9499
Practice Address - Country:US
Practice Address - Phone:574-528-0888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist