Provider Demographics
NPI:1720113434
Name:EVERSON, RONALD BLAINE (PHD)
Entity type:Individual
Prefix:DR
First Name:RONALD
Middle Name:BLAINE
Last Name:EVERSON
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 1:1361 JENNINGS MILL RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BOGART
Mailing Address - State:GA
Mailing Address - Zip Code:30622-2579
Mailing Address - Country:US
Mailing Address - Phone:706-316-1908
Mailing Address - Fax:706-316-2026
Practice Address - Street 1:1361 JENNINGS MILL RD
Practice Address - Street 2:SUITE 201
Practice Address - City:BOGART
Practice Address - State:GA
Practice Address - Zip Code:30622-2579
Practice Address - Country:US
Practice Address - Phone:706-316-1908
Practice Address - Fax:706-316-2026
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000776106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA793969025AMedicaid