Healthcare Provider Details

I. General information

NPI: 1235626938
Provider Name (Legal Business Name): ANDREA AVERY LCPC-C LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 09/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 STONE ST STE 101
AUGUSTA ME
04330-5209
US

IV. Provider business mailing address

45 HASKELL HAVEN RD
WINDSOR ME
04363-3264
US

V. Phone/Fax

Practice location:
  • Phone: 207-446-5773
  • Fax:
Mailing address:
  • Phone: 207-446-5773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLC6482
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberXL5046
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: