Provider Demographics
NPI:1871364497
Name:FOSS, AVERY AUTUMN
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:AUTUMN
Last Name:FOSS
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 1:2497 CREEKFRONT DR
Mailing Address - Street 2:
Mailing Address - City:GREEN COVE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32043-6220
Mailing Address - Country:US
Mailing Address - Phone:904-325-5442
Mailing Address - Fax:
Practice Address - Street 1:2377 MARKET DR
Practice Address - Street 2:
Practice Address - City:FLEMING ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32003-4326
Practice Address - Country:US
Practice Address - Phone:904-579-4779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-11
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician