Provider Demographics
NPI:1902636400
Name:BLACK, AVERY CAROLYNN
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:CAROLYNN
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 WARD PKWY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-1709
Mailing Address - Country:US
Mailing Address - Phone:817-889-3032
Mailing Address - Fax:
Practice Address - Street 1:1801 ROYAL LN STE 300
Practice Address - Street 2:
Practice Address - City:FARMERS BRANCH
Practice Address - State:TX
Practice Address - Zip Code:75229-3179
Practice Address - Country:US
Practice Address - Phone:888-754-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician