Provider Demographics
NPI:1417784992
Name:EVERETT, CORY
Entity type:Individual
Prefix:
First Name:CORY
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:PO BOX 1294
Mailing Address - Street 2:
Mailing Address - City:CAPITAN
Mailing Address - State:NM
Mailing Address - Zip Code:88316-1294
Mailing Address - Country:US
Mailing Address - Phone:575-973-2396
Mailing Address - Fax:
Practice Address - Street 1:199 WHITE MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:RUIDOSO
Practice Address - State:NM
Practice Address - Zip Code:88345
Practice Address - Country:US
Practice Address - Phone:575-258-9494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSAH-2024-0298235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist