Provider Demographics
NPI:1467233692
Name:RIEMERSMA, AVREY
Entity Type:Individual
Prefix:
First Name:AVREY
Middle Name:
Last Name:RIEMERSMA
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 1:2060 E 2650 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:MARTINTON
Mailing Address - State:IL
Mailing Address - Zip Code:60951-6071
Mailing Address - Country:US
Mailing Address - Phone:219-688-9570
Mailing Address - Fax:
Practice Address - Street 1:500 BROWN BLVD
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2328
Practice Address - Country:US
Practice Address - Phone:219-688-9570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-12
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.019477101YM0800X
IN88002141A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health