Healthcare Provider Details

I. General information

NPI: 1104091925
Provider Name (Legal Business Name): ANGELA MARIE AVERY LMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2008
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 MERRILL DR
MILTON FL
32570-4142
US

IV. Provider business mailing address

308 MERRILL DR
MILTON FL
32570-4142
US

V. Phone/Fax

Practice location:
  • Phone: 850-773-6276
  • Fax:
Mailing address:
  • Phone: 850-736-2767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH9279
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: