Provider Demographics
NPI:1003933748
Name:MARK, AVERIL KAYLA (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AVERIL
Middle Name:KAYLA
Last Name:MARK
Suffix:
Gender:F
Credentials:MS,CCC-SLP
Other - Prefix:
Other - First Name:AVERIL
Other - Middle Name:KAYLA
Other - Last Name:HOSTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,CCC-SLP
Mailing Address - Street 1:12207 SW 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33025-5927
Mailing Address - Country:US
Mailing Address - Phone:954-683-7090
Mailing Address - Fax:
Practice Address - Street 1:12207 SW 6TH ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33025-5927
Practice Address - Country:US
Practice Address - Phone:954-683-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6383235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL888346700Medicaid