Provider Demographics
NPI:1073298345
Name:MEDEIROS, AVA ELIZABETH
Entity Type:Individual
Prefix:
First Name:AVA
Middle Name:ELIZABETH
Last Name:MEDEIROS
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 1:5 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02347-1724
Mailing Address - Country:US
Mailing Address - Phone:774-260-1937
Mailing Address - Fax:
Practice Address - Street 1:136A ARCH ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-2186
Practice Address - Country:US
Practice Address - Phone:603-357-3902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist