Provider Demographics
NPI:1811238355
Name:AVERY, ASHLEY ATWATER (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:ATWATER
Last Name:AVERY
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MS
Other - First Name:ASHLEY
Other - Middle Name:WEBSTER
Other - Last Name:ATWATER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:731 PRE EMPTION RD
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:NY
Mailing Address - Zip Code:14456-1335
Mailing Address - Country:US
Mailing Address - Phone:315-789-6828
Mailing Address - Fax:315-789-7750
Practice Address - Street 1:5415 N BLOOMFIELD RD
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-7964
Practice Address - Country:US
Practice Address - Phone:585-394-9510
Practice Address - Fax:585-394-5326
Is Sole Proprietor?:No
Enumeration Date:2013-03-08
Last Update Date:2013-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022478-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03574141Medicaid