Provider Demographics
NPI:1508390667
Name:AVERETT, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:AVERETT
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 1:6200 BELLECLIFF RUN
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-8628
Mailing Address - Country:US
Mailing Address - Phone:954-531-4790
Mailing Address - Fax:
Practice Address - Street 1:6200 BELLECLIFF RUN
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-8628
Practice Address - Country:US
Practice Address - Phone:954-531-4790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-16
Last Update Date:2017-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0060571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical