Provider Demographics
NPI:1346953114
Name:BEAL, AVERY (PT)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:BEAL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 FAIRWAY LAKES DR
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-3845
Mailing Address - Country:US
Mailing Address - Phone:223-335-3212
Mailing Address - Fax:
Practice Address - Street 1:249 MACK BAYOU LOOP STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ROSA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32459-7197
Practice Address - Country:US
Practice Address - Phone:850-622-0842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-27
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL34582225100000X
FLPT34582225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist