Provider Demographics
NPI:1184183840
Name:AVERILL, KYLIE
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:AVERILL
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 1:373 S WILLOW ST STE 266
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03103-5751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22530 FISHER RD
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-1050
Practice Address - Country:US
Practice Address - Phone:877-315-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst