Provider Demographics
NPI:1083259329
Name:AVITABILE, ANTHONY VIDAURRI
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:VIDAURRI
Last Name:AVITABILE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13223 BLACK MOUNTAIN RD # 1358
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92129-2698
Mailing Address - Country:US
Mailing Address - Phone:858-753-5082
Mailing Address - Fax:
Practice Address - Street 1:13223 BLACK MOUNTAIN RD # 1358
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-2698
Practice Address - Country:US
Practice Address - Phone:858-753-5082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28983235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist