Basic Information
| Provider Information | |||||||||
| NPI: | 1821526831 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVERY | ||||||||
| FirstName: | CASSANDRA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CRC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CORP | ||||||||
| OtherFirstName: | CASSANDRA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 34 ORGAN CRES | ||||||||
| Address2: | |||||||||
| City: | WEST SENECA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142241616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168305949 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 430 NIAGARA ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142011886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168562587 | ||||||||
| FaxNumber: | 7168562608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2017 | ||||||||
| LastUpdateDate: | 06/03/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.