Provider Demographics
NPI:1447877113
Name:LISS, AVERY J (MHP)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:J
Last Name:LISS
Suffix:
Gender:M
Credentials:MHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 GREENVIEW DR APT 4
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-3041
Mailing Address - Country:US
Mailing Address - Phone:217-994-4445
Mailing Address - Fax:
Practice Address - Street 1:218 E MAIN ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2114
Practice Address - Country:US
Practice Address - Phone:618-395-8656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health