Provider Demographics
NPI:1043104797
Name:BLACK, AVERY CHRISTIAN LEE (HIS)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:CHRISTIAN LEE
Last Name:BLACK
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 CRYE LEIKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-4055
Mailing Address - Country:US
Mailing Address - Phone:706-858-8832
Mailing Address - Fax:
Practice Address - Street 1:89 CRYE LEIKE DR
Practice Address - Street 2:
Practice Address - City:FORT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-4055
Practice Address - Country:US
Practice Address - Phone:706-858-8832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-06
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAHADS001156237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist