=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912790916
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVERY MCCOY GARDNER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2025
-----------------------------------------------------
Last Update Date | 05/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1233 SHELBURNE RD STE 203
-----------------------------------------------------
City | SOUTH BURLINGTON
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05403-7733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 802-391-0704
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 WEST ST APT A
-----------------------------------------------------
City | WINOOSKI
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05404-1775
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 609-661-2423
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | C.2406382
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 097.0136418
-----------------------------------------------------
License Number State | VT
-----------------------------------------------------