=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154456432
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MESHI AVERY M.ED, NCC, LPC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 12/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 696 MOUNT ZION RD STE B7
-----------------------------------------------------
City | JONESBORO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30236-1582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-827-3232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3695 CASCADE RD SW # F-217
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30331-2173
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-827-3232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC005444
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------