Provider Demographics
NPI:1063982858
Name:PEELEN, AVERY (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:AVERY
Middle Name:
Last Name:PEELEN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MISS
Other - First Name:AVERY
Other - Middle Name:
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1110 E 45TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-4507
Mailing Address - Country:US
Mailing Address - Phone:918-971-9444
Mailing Address - Fax:
Practice Address - Street 1:1110 E 45TH PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-4507
Practice Address - Country:US
Practice Address - Phone:918-971-9444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4996235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist