Provider Demographics
NPI:1235293762
Name:AVERY, REBECCA BANAHAN (LCSW)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:BANAHAN
Last Name: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 1:428 N LAMAR BLVD
Mailing Address - Street 2:STE 113
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-3221
Mailing Address - Country:US
Mailing Address - Phone:662-234-4876
Mailing Address - Fax:
Practice Address - Street 1:428 N LAMAR BLVD
Practice Address - Street 2:STE 113
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-3221
Practice Address - Country:US
Practice Address - Phone:662-234-4876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC83141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI56746Medicare ID - Type Unspecified