Healthcare Provider Details

I. General information

NPI: 1922938448
Provider Name (Legal Business Name): AVERY LIAM RASON CTRS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W BARAGA AVE
MARQUETTE MI
49855-4550
US

IV. Provider business mailing address

110 S 18TH ST APT C
COLORADO SPRINGS CO
80904-3869
US

V. Phone/Fax

Practice location:
  • Phone: 906-449-3000
  • Fax:
Mailing address:
  • Phone: 910-512-2325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number84050
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: