Provider Demographics
NPI:1225758279
Name:DESY, AVERY NICOLE
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:NICOLE
Last Name:DESY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4603 TYLER ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51108-1129
Mailing Address - Country:US
Mailing Address - Phone:712-203-8819
Mailing Address - Fax:
Practice Address - Street 1:620 COURT ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1920
Practice Address - Country:US
Practice Address - Phone:712-252-3871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1009841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical