Healthcare Provider Details

I. General information

NPI: 1679266936
Provider Name (Legal Business Name): AVERY SIERRA HEYWOOD MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AVERY BASIL MSW

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 06/01/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 WEST SPARKS ST
PHILADELPHIA PA
19141
US

IV. Provider business mailing address

1305 W CHESTER PIKE STE 18
HAVERTOWN PA
19083-2929
US

V. Phone/Fax

Practice location:
  • Phone: 215-346-6684
  • Fax:
Mailing address:
  • Phone: 215-346-6684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: