Provider Demographics
NPI:1407105786
Name:AVERA, CHARLES ALLEN JR (MA, LPC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:ALLEN
Last Name:AVERA
Suffix:JR
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 MAXWELL RD
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27517-4042
Mailing Address - Country:US
Mailing Address - Phone:919-923-3814
Mailing Address - Fax:
Practice Address - Street 1:104 MAXWELL RD
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27517-4042
Practice Address - Country:US
Practice Address - Phone:919-923-3814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-02
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8383101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
12454514OtherCAQH
NC6115063Medicaid