Healthcare Provider Details

I. General information

NPI: 1417333717
Provider Name (Legal Business Name): KRISTI EVERETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17505 N 79TH AVE STE 211E
GLENDALE AZ
85308-8725
US

IV. Provider business mailing address

17505 N 79TH AVE STE 211E
GLENDALE AZ
85308-8725
US

V. Phone/Fax

Practice location:
  • Phone: 602-688-4027
  • Fax:
Mailing address:
  • Phone: 602-688-4027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-13335
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12359872-3501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-17498
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: