MEDICARE: DR. CONSTANCE AVERILL PH.D, LMSW, ACSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	L877869	MI
2	1041C0700X	Clinical Social Worker	6801082009	MI

General Provider Information

NPI Number	:	1831338441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CONSTANCE AVERILL PH.D, LMSW, ACSW

Provider Business Mailing Address
First Line	:	3785 BAY RD
Second Line	:
City	:	SAGINAW
State	:	MI
Zip	:	48603-2433
Country	:	US
Telephone Number	:	989-791-2455
Fax Number	:

Provider Business Practice Location Address
First Line	:	4020 COPPER VW STE 104
Second Line	:
City	:	TRAVERSE CITY
State	:	MI
Zip	:	49684-7041
Country	:	US
Telephone Number	:	231-421-6921
Fax Number	:	231-421-7852

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2009
Last Update Date	:	12/16/2020

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