Provider Demographics
NPI:1184242687
Name:MITEVSKI, AVERY QUINN (MS TLLP)
Entity type:Individual
Prefix:MRS
First Name:AVERY
Middle Name:QUINN
Last Name:MITEVSKI
Suffix:
Gender:F
Credentials:MS TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8671 FOSTER RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-1962
Mailing Address - Country:US
Mailing Address - Phone:248-872-3288
Mailing Address - Fax:
Practice Address - Street 1:3069 UNIVERSITY DR STE 250
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2388
Practice Address - Country:US
Practice Address - Phone:248-564-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362006147103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical