Provider Demographics
NPI:1538593512
Name:EVERETT, KERRI (SLP)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:
Last Name:EVERETT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6507
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-6507
Mailing Address - Country:US
Mailing Address - Phone:208-720-9982
Mailing Address - Fax:
Practice Address - Street 1:220 S 2ND AVENUE, #101
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340
Practice Address - Country:US
Practice Address - Phone:208-720-9982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1958235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist