Provider Demographics
NPI:1972729622
Name:ELLER, AVA S
Entity Type:Individual
Prefix:MS
First Name:AVA
Middle Name:S
Last Name:ELLER
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:PO BOX 326
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:VT
Mailing Address - Zip Code:05445-0326
Mailing Address - Country:US
Mailing Address - Phone:802-651-7527
Mailing Address - Fax:802-863-2170
Practice Address - Street 1:3 MAIN ST
Practice Address - Street 2:SUITE 107
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5216
Practice Address - Country:US
Practice Address - Phone:802-651-7527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0470000624103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1005140Medicaid