Provider Demographics
NPI:1811133770
Name:AVERY, CHARLES JAMES (CAC III)
Entity type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:JAMES
Last Name:AVERY
Suffix:
Gender:M
Credentials:CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 RAM AVE.
Mailing Address - Street 2:
Mailing Address - City:FORT MORGAN
Mailing Address - State:CO
Mailing Address - Zip Code:80701
Mailing Address - Country:US
Mailing Address - Phone:970-370-3940
Mailing Address - Fax:
Practice Address - Street 1:410 RAILROAD AVE.
Practice Address - Street 2:
Practice Address - City:FORT MORGAN
Practice Address - State:CO
Practice Address - Zip Code:80701
Practice Address - Country:US
Practice Address - Phone:970-370-3940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-24
Last Update Date:2008-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1596-01101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)