Provider Demographics
NPI:1215308648
Name:AVERY, MARYANNE (MA, CAC III)
Entity type:Individual
Prefix:
First Name:MARYANNE
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:MA, CAC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4091
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-4091
Mailing Address - Country:US
Mailing Address - Phone:720-394-9869
Mailing Address - Fax:
Practice Address - Street 1:1432 GRAND AVE
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-3808
Practice Address - Country:US
Practice Address - Phone:172-039-4986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-12
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0020794101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)