MEDICARE: KRISTI EVERETT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	12359872-3501	UT
2	1041C0700X	Clinical Social Worker	LCSW-17498	AZ
3	104100000X	Social Worker	LMSW-13335	AZ

General Provider Information

NPI Number	:	1417333717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTI EVERETT

Provider Business Mailing Address
First Line	:	17505 N 79TH AVE STE 211E
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8725
Country	:	US
Telephone Number	:	602-688-4027
Fax Number	:

Provider Business Practice Location Address
First Line	:	17505 N 79TH AVE STE 211E
Second Line	:
City	:	GLENDALE
State	:	AZ
Zip	:	85308-8725
Country	:	US
Telephone Number	:	602-688-4027
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2015
Last Update Date	:	07/12/2022

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Directions to “ KRISTI EVERETT ” Practice Location

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