Provider Demographics
NPI:1376045518
Name:AVERY, QUIANEA
Entity Type:Individual
Prefix:
First Name:QUIANEA
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 S MARTIN L KING BLVD APT 261
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-4320
Mailing Address - Country:US
Mailing Address - Phone:818-693-2025
Mailing Address - Fax:
Practice Address - Street 1:7390 W SAHARA AVE STE 240
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-2764
Practice Address - Country:US
Practice Address - Phone:702-816-3983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-04
Last Update Date:2018-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health