MEDICARE: MRS. MARY THERESE EVERETT MA

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	231H00000X	Audiologist	23002170A	IN
2	231HA2400X	Assistive Technology Practitioner Audiologist	23002170A	IN
3	237600000X	Audiologist-Hearing Aid Fitter	23002170A	IN

General Provider Information

NPI Number	:	1528217064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY THERESE EVERETT MA

Provider Business Mailing Address
First Line	:	9131 LIMA RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-1803
Country	:	US
Telephone Number	:	260-489-2693
Fax Number	:	260-489-1495

Provider Business Practice Location Address
First Line	:	9131 LIMA RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-1803
Country	:	US
Telephone Number	:	260-489-2693
Fax Number	:	260-489-1495

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

Provider Enumeration Date	:	09/09/2008
Last Update Date	:	09/09/2008

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