Healthcare Provider Details

I. General information

NPI: 1609576321
Provider Name (Legal Business Name): AVERY JOSEPH GEORGE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 03/09/2023
Certification Date: 03/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 GREENBRIAR DR
SOUTHLAKE TX
76092-8355
US

IV. Provider business mailing address

1039 FRANKLIN AVE
RIVER FOREST IL
60305-1339
US

V. Phone/Fax

Practice location:
  • Phone: 817-442-9022
  • Fax: --
Mailing address:
  • Phone: 224-240-3096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-23-259665
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: