1467884833 NPI number — MOLLY C EVERSON MS, CCC-SLP

Table of content: MOLLY C EVERSON MS, CCC-SLP (NPI 1467884833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467884833 NPI number — MOLLY C EVERSON MS, CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVERSON
Provider First Name:
MOLLY
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467884833
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2994
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WENATCHEE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98807-2994
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-888-3062
Provider Business Mailing Address Fax Number:
509-888-3063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
528 E SPOKANE FALLS BLVD
Provider Second Line Business Practice Location Address:
STE 401
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99202-5050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-435-0481
Provider Business Practice Location Address Fax Number:
509-435-0485
Provider Enumeration Date:
08/07/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  LL 60389626 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7121189 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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