Provider Demographics
NPI:1407598279
Name:AVERY, SHANICE NICOLE
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:NICOLE
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 1:138 ELMUR DR APT 807
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-6172
Mailing Address - Country:US
Mailing Address - Phone:724-630-6960
Mailing Address - Fax:
Practice Address - Street 1:101 N MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-2407
Practice Address - Country:US
Practice Address - Phone:724-302-0804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW137712104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker