Provider Demographics
NPI:1225604820
Name:LITTLE, AVONDRE R
Entity Type:Individual
Prefix:
First Name:AVONDRE
Middle Name:R
Last Name:LITTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 TACOMA AVE S STE 305
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1903
Mailing Address - Country:US
Mailing Address - Phone:253-381-5168
Mailing Address - Fax:
Practice Address - Street 1:1305 TACOMA AVE S STE 305
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-1903
Practice Address - Country:US
Practice Address - Phone:253-396-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty