Provider Demographics
NPI:1285400846
Name:EVERETT, GREGORY (PHD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:EVERETT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2237 TRAMORE
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:IL
Mailing Address - Zip Code:62294-9001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2237 TRAMORE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:IL
Practice Address - Zip Code:62294-9001
Practice Address - Country:US
Practice Address - Phone:618-960-7756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TS0200X
IL071007380103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool