Provider Demographics
NPI:1518573476
Name:WARNER, AVERY ROSE
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:ROSE
Last Name:WARNER
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 1:3475 ROMULUS DR
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-3443
Mailing Address - Country:US
Mailing Address - Phone:404-861-4648
Mailing Address - Fax:
Practice Address - Street 1:3475 ROMULUS DR
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-3443
Practice Address - Country:US
Practice Address - Phone:404-861-4648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-20-119084106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician