Provider Demographics
NPI:1801457825
Name:PHELAN, AVERY
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:PHELAN
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 1:565 WILLOW RD APT 26
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-2654
Mailing Address - Country:US
Mailing Address - Phone:650-796-2349
Mailing Address - Fax:
Practice Address - Street 1:565 WILLOW RD APT 26
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-2654
Practice Address - Country:US
Practice Address - Phone:650-796-2349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician