Provider Demographics
NPI:1497377881
Name:AVERY, LEE JOHN
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:JOHN
Last Name:AVERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 LITT DR
Mailing Address - Street 2:
Mailing Address - City:HILLSIDE
Mailing Address - State:IL
Mailing Address - Zip Code:60162-1120
Mailing Address - Country:US
Mailing Address - Phone:708-547-3560
Mailing Address - Fax:
Practice Address - Street 1:4110 LITT DR
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:IL
Practice Address - Zip Code:60162-1120
Practice Address - Country:US
Practice Address - Phone:708-547-3560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-08
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst