Healthcare Provider Details

I. General information

NPI: 1104629989
Provider Name (Legal Business Name): AVERY MAE RICHARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2025
Last Update Date: 08/22/2025
Certification Date: 08/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

233 NEEDHAM ST STE 430
NEWTON MA
02464-1534
US

IV. Provider business mailing address

PO BOX 1343
WESTBOROUGH MA
01581-6343
US

V. Phone/Fax

Practice location:
  • Phone: 617-830-1644
  • Fax:
Mailing address:
  • Phone: 978-621-9938
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2293755
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2293755
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: