Provider Demographics
NPI:1710292156
Name:AVERILL, MARY K (LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:K
Last Name:AVERILL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:6 SCHOOL ST
Mailing Address - City:MONTAGUE
Mailing Address - State:MA
Mailing Address - Zip Code:01351-0159
Mailing Address - Country:US
Mailing Address - Phone:413-695-8633
Mailing Address - Fax:
Practice Address - Street 1:6 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:MA
Practice Address - Zip Code:01351-8918
Practice Address - Country:US
Practice Address - Phone:413-695-8633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-10
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
MA1174451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker