Provider Demographics
NPI:1659668366
Name:AVERY, ELIZABETH AUSTIN (MS RD CSO LDN CNSC)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:AUSTIN
Last Name:AVERY
Suffix:
Gender:F
Credentials:MS RD CSO LDN CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 SAINT BOTOLPH ST
Mailing Address - Street 2:APT. 4
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5169
Mailing Address - Country:US
Mailing Address - Phone:617-721-7865
Mailing Address - Fax:
Practice Address - Street 1:364 GRANITE AVE
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-5025
Practice Address - Country:US
Practice Address - Phone:617-698-0260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3015133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered