Provider Demographics
NPI:1801301593
Name:AVERA, CHARITY LYNN
Entity type:Individual
Prefix:
First Name:CHARITY
Middle Name:LYNN
Last Name:AVERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:327 EMMETT WHALEY RD
Mailing Address - Street 2:
Mailing Address - City:CRAWFORDVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32327-4075
Mailing Address - Country:US
Mailing Address - Phone:850-768-0544
Mailing Address - Fax:850-768-0544
Practice Address - Street 1:327 EMMETT WHALEY RD
Practice Address - Street 2:
Practice Address - City:CRAWFORDVILLE
Practice Address - State:FL
Practice Address - Zip Code:32327-4075
Practice Address - Country:US
Practice Address - Phone:850-768-0544
Practice Address - Fax:850-768-0544
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL18983225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant