MEDICARE: CHLOE MARIE EVERETT SAC-IT

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	20461-130	WI

General Provider Information

NPI Number	:	1912776634
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHLOE MARIE EVERETT SAC-IT

Provider Business Mailing Address
First Line	:	5194 E CHERYL PKWY APT 104
Second Line	:
City	:	FITCHBURG
State	:	WI
Zip	:	53711-7710
Country	:	US
Telephone Number	:	608-692-2769
Fax Number	:

Provider Business Practice Location Address
First Line	:	131 CLARMAR DR
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-2664
Country	:	US
Telephone Number	:	608-318-0932
Fax Number	:

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

Provider Enumeration Date	:	12/21/2023
Last Update Date	:	12/21/2023

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