Provider Demographics
NPI:1669098224
Name:AVERILL, KARLA MARIE (MA,LLP)
Entity type:Individual
Prefix:
First Name:KARLA
Middle Name:MARIE
Last Name:AVERILL
Suffix:
Gender:F
Credentials:MA,LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6700 BRUTUS RD
Mailing Address - Street 2:
Mailing Address - City:BRUTUS
Mailing Address - State:MI
Mailing Address - Zip Code:49716-9710
Mailing Address - Country:US
Mailing Address - Phone:623-337-2747
Mailing Address - Fax:
Practice Address - Street 1:890 N 10TH ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-6192
Practice Address - Country:US
Practice Address - Phone:269-427-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361003377103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI12345Medicaid