Provider Demographics
NPI:1073661674
Name:AVERY, GREG L (MS-SLP)
Entity Type:Individual
Prefix:MR
First Name:GREG
Middle Name:L
Last Name:AVERY
Suffix:
Gender:M
Credentials:MS-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 CHOLLA CIR
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-1246
Mailing Address - Country:US
Mailing Address - Phone:520-459-8910
Mailing Address - Fax:
Practice Address - Street 1:70 E PATTON ST
Practice Address - Street 2:
Practice Address - City:SAINT DAVID
Practice Address - State:AZ
Practice Address - Zip Code:85630-6207
Practice Address - Country:US
Practice Address - Phone:520-720-4781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist