Provider Demographics
NPI:1366009656
Name:NGUYEN, AVERY L (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:L
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:AVERY
Other - Middle Name:
Other - Last Name:NGUYEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:120 STEVENS ST SW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-1526
Mailing Address - Country:US
Mailing Address - Phone:616-482-7109
Mailing Address - Fax:616-469-3870
Practice Address - Street 1:120 STEVENS ST SW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-1526
Practice Address - Country:US
Practice Address - Phone:616-469-3870
Practice Address - Fax:616-469-3870
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-22
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 106S00000X
MI103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician