Provider Demographics
NPI:1437677804
Name:ROBERTO, AVERILL
Entity Type:Individual
Prefix:
First Name:AVERILL
Middle Name:
Last Name:ROBERTO
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 1:1640 BORO PL FL 4
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22102-3627
Mailing Address - Country:US
Mailing Address - Phone:323-522-2218
Mailing Address - Fax:
Practice Address - Street 1:1640 BORO PL FL 4
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22102-3627
Practice Address - Country:US
Practice Address - Phone:323-522-2218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-06
Last Update Date:2023-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY09543241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical