Provider Demographics
NPI:1265785836
Name:AVERY, KENTRELL MONIQUE (PSYD)
Entity type:Individual
Prefix:DR
First Name:KENTRELL
Middle Name:MONIQUE
Last Name:AVERY
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 VETERANS MEMORIAL DRIVE
Mailing Address - Street 2:U.S. DEPARTMENT OF VETERANS AFFAIRS
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76504
Mailing Address - Country:US
Mailing Address - Phone:254-743-2867
Mailing Address - Fax:254-743-0304
Practice Address - Street 1:1901 VETERANS MEMORIAL DRIVE
Practice Address - Street 2:U.S. DEPARTMENT OF VETERANS AFFAIRS
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76504
Practice Address - Country:US
Practice Address - Phone:254-743-2867
Practice Address - Fax:254-743-0304
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-19
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1217103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAN/AOtherN/A