Provider Demographics
NPI:1881925709
Name:AVERY, JOHNNA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:JOHNNA
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 CAPE NEDDICK RD
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:ME
Mailing Address - Zip Code:03909-6132
Mailing Address - Country:US
Mailing Address - Phone:207-450-6529
Mailing Address - Fax:
Practice Address - Street 1:41 CAPE NEDDICK RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:ME
Practice Address - Zip Code:03909-6132
Practice Address - Country:US
Practice Address - Phone:207-450-6529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1114235Z00000X
MESP1348235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist