Provider Demographics
NPI:1891300109
Name:BAVIS, AUDREY (LMT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:BAVIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 SOUTH RD
Mailing Address - Street 2:
Mailing Address - City:MILLBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:12545-5527
Mailing Address - Country:US
Mailing Address - Phone:845-505-2843
Mailing Address - Fax:845-605-1307
Practice Address - Street 1:104 SOUTH RD
Practice Address - Street 2:
Practice Address - City:MILLBROOK
Practice Address - State:NY
Practice Address - Zip Code:12545-5527
Practice Address - Country:US
Practice Address - Phone:845-505-2843
Practice Address - Fax:845-605-1307
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032186225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist