Provider Demographics
NPI:1386952166
Name:AVERY, MARY ELIZABETH (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:AVERY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:MARY BETH
Other - Middle Name:
Other - Last Name:RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:4515 TIMOTHY WAY
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-9161
Mailing Address - Country:US
Mailing Address - Phone:502-797-9681
Mailing Address - Fax:
Practice Address - Street 1:6317 HIGHWAY 329
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-9040
Practice Address - Country:US
Practice Address - Phone:502-384-0910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-15
Last Update Date:2020-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3806235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist