Provider Demographics
NPI:1093263469
Name:EVERLY, MICHAEL (LMT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:EVERLY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11414 152ND ST E APT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-9357
Mailing Address - Country:US
Mailing Address - Phone:425-502-2266
Mailing Address - Fax:
Practice Address - Street 1:10612 CANYON RD E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-4257
Practice Address - Country:US
Practice Address - Phone:253-302-4817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-14
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60434761225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist