Provider Demographics
NPI:1932129426
Name:AVILES, ELLENORA E (OTRL)
Entity Type:Individual
Prefix:
First Name:ELLENORA
Middle Name:E
Last Name:AVILES
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6588
Mailing Address - Street 2:ST MARYS HOME HEALTH CARE
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30604-9828
Mailing Address - Country:US
Mailing Address - Phone:706-389-2273
Mailing Address - Fax:706-208-8883
Practice Address - Street 1:1500 OGLETHORPE AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2179
Practice Address - Country:US
Practice Address - Phone:706-389-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001956225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics