Healthcare Provider Details

I. General information

NPI: 1922353481
Provider Name (Legal Business Name): TEGRIN AVERETT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2012
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7950 MARTIN LOOP
FORT BENNING GA
31905-5648
US

IV. Provider business mailing address

3318 CARAVELLE DR
COLUMBUS GA
31909-5126
US

V. Phone/Fax

Practice location:
  • Phone: 706-544-1442
  • Fax:
Mailing address:
  • Phone: 706-289-6584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004536
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLW00004890
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: