Provider Demographics
NPI:1285658229
Name:AVERY, BETH B (LCSW)
Entity Type:Individual
Prefix:MS
First Name:BETH
Middle Name:B
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:PO BOX 253
Mailing Address - Street 2:
Mailing Address - City:OLD MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06372-0253
Mailing Address - Country:US
Mailing Address - Phone:860-572-0667
Mailing Address - Fax:860-572-0667
Practice Address - Street 1:5 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2717
Practice Address - Country:US
Practice Address - Phone:860-572-0667
Practice Address - Fax:860-572-0667
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004996101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional