Provider Demographics
NPI:1275869299
Name:AVERY, JOHN CLIFFORD (LICSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CLIFFORD
Last Name:AVERY
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12838 HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-5209
Mailing Address - Country:US
Mailing Address - Phone:320-360-4880
Mailing Address - Fax:320-639-0220
Practice Address - Street 1:12838 HIGHWAY 27
Practice Address - Street 2:
Practice Address - City:LITTLE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56345-5209
Practice Address - Country:US
Practice Address - Phone:320-360-4880
Practice Address - Fax:320-639-0220
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-27
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN125651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical