Provider Demographics
NPI:1477624161
Name:AVERILL, CHARLES EDGAR JR (OTR L)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:EDGAR
Last Name:AVERILL
Suffix:JR
Gender:M
Credentials:OTR L
Other - Prefix:MR
Other - First Name:SKIP
Other - Middle Name:
Other - Last Name:AVERILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:74 MANOR CREST DR
Mailing Address - Street 2:
Mailing Address - City:KIRKSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63501-3356
Mailing Address - Country:US
Mailing Address - Phone:660-627-2260
Mailing Address - Fax:
Practice Address - Street 1:704A SOUTH MISSOURI
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MO
Practice Address - Zip Code:63552
Practice Address - Country:US
Practice Address - Phone:660-385-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006013588225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist