Provider Demographics
NPI:1245779925
Name:ROSSER, AVERY (LPC)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:ROSSER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 HIGHPOINT RD STE 122
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3189
Mailing Address - Country:US
Mailing Address - Phone:770-629-8669
Mailing Address - Fax:
Practice Address - Street 1:2330 SCENIC HWY S
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3115
Practice Address - Country:US
Practice Address - Phone:770-629-8669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-15
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009368101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003190224AMedicaid