Provider Demographics
NPI:1083432512
Name:AVON BEHAVIORAL SERVICES LLC
Entity type:Organization
Organization Name:AVON BEHAVIORAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAQUAIL
Authorized Official - Middle Name:M
Authorized Official - Last Name:MONTGOMERY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-825-6012
Mailing Address - Street 1:629 LOFTY LN SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-8638
Mailing Address - Country:US
Mailing Address - Phone:510-825-6012
Mailing Address - Fax:
Practice Address - Street 1:4485 VERDON ST UNIT 1161
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-4431
Practice Address - Country:US
Practice Address - Phone:510-825-6012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health