Provider Demographics
NPI:1811545882
Name:MATCH, AVIVA MICHELLE
Entity Type:Individual
Prefix:
First Name:AVIVA
Middle Name:MICHELLE
Last Name:MATCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 BAYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21209-4001
Mailing Address - Country:US
Mailing Address - Phone:717-395-6247
Mailing Address - Fax:
Practice Address - Street 1:6901 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-3780
Practice Address - Country:US
Practice Address - Phone:717-395-6247
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2019-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD235Z00000X
MD01969L235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist