MEDICARE: VIRGINIA AVERY LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041S0200X	School Social Worker	72584	MT

General Provider Information

NPI Number	:	1396564126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIRGINIA AVERY LCSW

Provider Business Mailing Address
First Line	:	1018 BURLINGTON AVE STE 205
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801-5666
Country	:	US
Telephone Number	:	406-880-6417
Fax Number	:

Provider Business Practice Location Address
First Line	:	1018 BURLINGTON AVE STE 205
Second Line	:
City	:	MISSOULA
State	:	MT
Zip	:	59801-5666
Country	:	US
Telephone Number	:	406-880-6417
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2024
Last Update Date	:	10/08/2024

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