Provider Demographics
NPI:1750688768
Name:AVERY, ALTHEA LYNN (LISW-S)
Entity Type:Individual
Prefix:
First Name:ALTHEA
Middle Name:LYNN
Last Name:AVERY
Suffix:
Gender:F
Credentials:LISW-S
Other - Prefix:
Other - First Name:LYNN
Other - Middle Name:
Other - Last Name:AVERY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LISW-SUPV
Mailing Address - Street 1:10100 ELIDA RD
Mailing Address - Street 2:
Mailing Address - City:DELPHOS
Mailing Address - State:OH
Mailing Address - Zip Code:45833-9058
Mailing Address - Country:US
Mailing Address - Phone:419-695-8010
Mailing Address - Fax:419-695-0004
Practice Address - Street 1:20600 CHAGRIN BLVD STE 320
Practice Address - Street 2:
Practice Address - City:SHAKER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44122-5334
Practice Address - Country:US
Practice Address - Phone:216-295-7239
Practice Address - Fax:216-295-7240
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI.0009330-SUPV1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0268768Medicaid