Provider Demographics
NPI:1235626938
Name:AVERY, ANDREA (LCPC-C LADC)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:LCPC-C LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 HASKELL HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:ME
Mailing Address - Zip Code:04363-3264
Mailing Address - Country:US
Mailing Address - Phone:207-446-5773
Mailing Address - Fax:
Practice Address - Street 1:24 STONE ST STE 101
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-5209
Practice Address - Country:US
Practice Address - Phone:207-446-5773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL5046101YP2500X
MELC6482101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional