Provider Demographics
NPI:1437687308
Name:AVERY, ASHLIE LEANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:ASHLIE
Middle Name:LEANNE
Last Name:AVERY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 VETERANS PKWY S
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31788-6705
Mailing Address - Country:US
Mailing Address - Phone:229-616-1044
Mailing Address - Fax:
Practice Address - Street 1:20 11TH AVE SE
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-5650
Practice Address - Country:US
Practice Address - Phone:229-616-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-23
Last Update Date:2017-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0060581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical