Healthcare Provider Details

I. General information

NPI: 1073494878
Provider Name (Legal Business Name): AVERY MILLS
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2025
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 VILLAGE SQUARE DR STE A
PADUCAH KY
42001-7448
US

IV. Provider business mailing address

521 STONECREST PKWY STE 101
SMYRNA TN
37167-6897
US

V. Phone/Fax

Practice location:
  • Phone: 270-391-2396
  • Fax:
Mailing address:
  • Phone: 615-549-6608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-470927
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: