Provider Demographics
NPI:1912145228
Name:EVERETT, MICHELLE R (CASAC)
Entity Type:Individual
Prefix:MS
First Name:MICHELLE
Middle Name:R
Last Name:EVERETT
Suffix:
Gender:F
Credentials:CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13417 166TH PL
Mailing Address - Street 2:APT. #10F
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3846
Mailing Address - Country:US
Mailing Address - Phone:347-392-2195
Mailing Address - Fax:
Practice Address - Street 1:14732 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11435-4042
Practice Address - Country:US
Practice Address - Phone:718-523-4242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY18234101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)