Provider Demographics
NPI:1386242386
Name:EVERETT, CHARLES EARL III (LCSW)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:EARL
Last Name:EVERETT
Suffix:III
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:CHARLES
Other - Middle Name:E
Other - Last Name:EVERETT
Other - Suffix:III
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:9009 GREAT HILLS TRL APT 2021
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-7145
Mailing Address - Country:US
Mailing Address - Phone:512-669-6219
Mailing Address - Fax:
Practice Address - Street 1:2501 W WILLIAM CANNON DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745-5281
Practice Address - Country:US
Practice Address - Phone:512-344-9189
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX621891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical