Provider Demographics
NPI:1386043289
Name:AVERY, CHARLES D (LMT)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:D
Last Name:AVERY
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:POST OFFICE BOX 784
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:MT
Mailing Address - Zip Code:59872
Mailing Address - Country:US
Mailing Address - Phone:406-822-1040
Mailing Address - Fax:
Practice Address - Street 1:120 SECOND AVE E.
Practice Address - Street 2:
Practice Address - City:SUPERIOR
Practice Address - State:MT
Practice Address - Zip Code:59872
Practice Address - Country:US
Practice Address - Phone:406-822-1040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC6171225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist