Healthcare Provider Details

I. General information

NPI: 1366009656
Provider Name (Legal Business Name): AVERY L NGUYEN MA, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AVERY NGUYEN

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 3 MILE RD NW SUITE 200
GRAND RAPIDS MI
49544-1691
US

IV. Provider business mailing address

600 3 MILE RD NW SUITE 200
GRAND RAPIDS MI
49544-1691
US

V. Phone/Fax

Practice location:
  • Phone: 616-482-7109
  • Fax: 616-469-3870
Mailing address:
  • Phone: 616-482-7109
  • Fax: 616-469-3870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: