Provider Demographics
NPI:1295018331
Name:AVALON PSYCHOLOGICAL CENTER, PLLC
Entity Type:Organization
Organization Name:AVALON PSYCHOLOGICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VAUNETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LPP
Authorized Official - Phone:606-677-0053
Mailing Address - Street 1:106 SOUTHPORT DR.
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501
Mailing Address - Country:US
Mailing Address - Phone:606-677-0053
Mailing Address - Fax:606-677-0060
Practice Address - Street 1:106 SOUTHPORT DR.
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501
Practice Address - Country:US
Practice Address - Phone:606-677-0053
Practice Address - Fax:606-677-0060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-26
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0864101YA0400X
KY0068103TC1900X
KY20571041C0700X
KY3501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty