Provider Demographics
NPI:1043384878
Name:EVERETT, ELYSE (LCSW)
Entity type:Individual
Prefix:MS
First Name:ELYSE
Middle Name:
Last Name:EVERETT
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 GREENLAWN RD
Mailing Address - Street 2:
Mailing Address - City:SOUND BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11789-1821
Mailing Address - Country:US
Mailing Address - Phone:631-793-0870
Mailing Address - Fax:631-849-3750
Practice Address - Street 1:28 JONES ST
Practice Address - Street 2:SUITE 200
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-2941
Practice Address - Country:US
Practice Address - Phone:631-793-0870
Practice Address - Fax:631-849-3750
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0203781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN823S1Medicare ID - Type Unspecified