Provider Demographics
NPI:1336588847
Name:EVERETT, VANESSA JEAN (PT, DPT)
Entity type:Individual
Prefix:
First Name:VANESSA
Middle Name:JEAN
Last Name:EVERETT
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 SAINT JULIAN PL
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-8712
Mailing Address - Country:US
Mailing Address - Phone:315-706-7546
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-1450
Practice Address - Country:US
Practice Address - Phone:706-721-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2021-12-13
Deactivation Date:2021-11-18
Deactivation Code:
Reactivation Date:2021-12-09
Provider Licenses
StateLicense IDTaxonomies
GAPT010011225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist