Provider Demographics
NPI:1487183752
Name:AVERY, MARIAH LYNNE (BCBA)
Entity Type:Individual
Prefix:
First Name:MARIAH
Middle Name:LYNNE
Last Name:AVERY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 ROBIN LN
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39819-6465
Mailing Address - Country:US
Mailing Address - Phone:229-726-5311
Mailing Address - Fax:229-231-3022
Practice Address - Street 1:188 ROBIN LN
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39819-6465
Practice Address - Country:US
Practice Address - Phone:229-726-5311
Practice Address - Fax:229-231-3022
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-18-29947103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst