Provider Demographics
NPI:1851873798
Name:AVERY, ALBERT (LMSW)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:
Last Name:AVERY
Suffix:
Gender:M
Credentials:LMSW
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 1666
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-1666
Mailing Address - Country:US
Mailing Address - Phone:505-860-3393
Mailing Address - Fax:
Practice Address - Street 1:1201 N 1ST ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NM
Practice Address - Zip Code:87413-5271
Practice Address - Country:US
Practice Address - Phone:505-634-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-102111041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1041S0200XMedicaid