Provider Demographics
NPI:1598948960
Name:AVERY, KEITH JOHN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:JOHN
Last Name:AVERY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 TENNYSON LN
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-0392
Mailing Address - Country:US
Mailing Address - Phone:630-637-5110
Mailing Address - Fax:630-637-5554
Practice Address - Street 1:1242 TENNYSON LN
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-0392
Practice Address - Country:US
Practice Address - Phone:630-637-5110
Practice Address - Fax:630-637-5554
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-08
Last Update Date:2007-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical