Provider Demographics
NPI:1659961282
Name:TAVILLA, KAREN LYNN (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KAREN
Middle Name:LYNN
Last Name:TAVILLA
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S BROADWAY
Mailing Address - Street 2:STE 1 PMB 307
Mailing Address - City:SALEM
Mailing Address - State:NH
Mailing Address - Zip Code:03079
Mailing Address - Country:US
Mailing Address - Phone:603-401-1562
Mailing Address - Fax:
Practice Address - Street 1:295 MAMMOTH RD
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-3095
Practice Address - Country:US
Practice Address - Phone:603-432-6941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3276235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist