Provider Demographics
NPI:1912051376
Name:EVERETT, MARY ELLEN (LCSW)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:EVERETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MARY ELLEN
Other - Middle Name:
Other - Last Name:CORDISCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:7450 HERITAGE VILLAGE PLAZA DR.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155
Mailing Address - Country:US
Mailing Address - Phone:703-989-0786
Mailing Address - Fax:571-261-1170
Practice Address - Street 1:7450 HERITAGE VILLAGE PLAZA DR.
Practice Address - Street 2:SUITE 101
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155
Practice Address - Country:US
Practice Address - Phone:703-989-0786
Practice Address - Fax:571-261-1170
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0904005256101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health