Provider Demographics
NPI:1316204381
Name:EVERETT, JUSTIN
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:EVERETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 W BROWN ST.
Mailing Address - Street 2:APT. B
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85281
Mailing Address - Country:US
Mailing Address - Phone:480-262-1542
Mailing Address - Fax:
Practice Address - Street 1:515 N MESA DR.
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201
Practice Address - Country:US
Practice Address - Phone:480-898-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator