Provider Demographics
NPI:1073140380
Name:KEEN-AVERY, ANDREA LYNETTE (LCSW)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNETTE
Last Name:KEEN-AVERY
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 1:184 SONATA CIR
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-4936
Mailing Address - Country:US
Mailing Address - Phone:443-986-6031
Mailing Address - Fax:
Practice Address - Street 1:184 SONATA CIR
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-4936
Practice Address - Country:US
Practice Address - Phone:443-986-6031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0046681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACSW004668OtherSTATE LICENSE