Healthcare Provider Details

I. General information

NPI: 1437331535
Provider Name (Legal Business Name): WILLIAM LEE EVERETT M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2007
Last Update Date: 11/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 68TH ST SE
GRAND RAPIDS MI
49548-6927
US

IV. Provider business mailing address

3351 36TH ST SE
GRAND RAPIDS MI
49512-2809
US

V. Phone/Fax

Practice location:
  • Phone: 616-559-5873
  • Fax:
Mailing address:
  • Phone: 616-559-5873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301002039
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801061468
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: