Provider Demographics
NPI:1790297885
Name:REID, AVERYL (MA, QMHP)
Entity Type:Individual
Prefix:
First Name:AVERYL
Middle Name:
Last Name:REID
Suffix:
Gender:F
Credentials:MA, QMHP
Other - Prefix:
Other - First Name:AVERYL
Other - Middle Name:
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9150 E 109TH AVE STE 1B
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-7686
Mailing Address - Country:US
Mailing Address - Phone:219-743-2488
Mailing Address - Fax:
Practice Address - Street 1:9150 E 109TH AVE STE 1B
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7686
Practice Address - Country:US
Practice Address - Phone:219-743-2488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-29
Last Update Date:2017-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty