Provider Demographics
NPI:1952582389
Name:AVERA, MICHAEL RAY (PTA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RAY
Last Name:AVERA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 WESTVIEW DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31705-9302
Mailing Address - Country:US
Mailing Address - Phone:850-420-4718
Mailing Address - Fax:
Practice Address - Street 1:1000 WESTVIEW DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-9302
Practice Address - Country:US
Practice Address - Phone:850-420-4718
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 20497225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant