Provider Demographics
NPI:1780200204
Name:SCOPELLITE, AVALON (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AVALON
Middle Name:
Last Name:SCOPELLITE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11998 STONEY PEAK DR APT 812
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92128-6473
Mailing Address - Country:US
Mailing Address - Phone:949-310-4002
Mailing Address - Fax:
Practice Address - Street 1:4002 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4506
Practice Address - Country:US
Practice Address - Phone:760-940-7151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-20
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26900235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty