Provider Demographics
NPI:1629714597
Name:AVISON, AUSTIN JAMES
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:JAMES
Last Name:AVISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170
Mailing Address - Country:US
Mailing Address - Phone:734-451-3440
Mailing Address - Fax:
Practice Address - Street 1:1360 PORTER ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2890
Practice Address - Country:US
Practice Address - Phone:313-689-5188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI6362009961103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician