Healthcare Provider Details

I. General information

NPI: 1235123134
Provider Name (Legal Business Name): ETHAN R EVERETT PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 09/28/2026
Certification Date: 09/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 N 3420 W
HURRICANE UT
84737-4417
US

IV. Provider business mailing address

416 N 3420 W
HURRICANE UT
84737-4417
US

V. Phone/Fax

Practice location:
  • Phone: 608-799-3292
  • Fax:
Mailing address:
  • Phone: 608-799-3292
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number9559981-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: