Healthcare Provider Details

I. General information

NPI: 1376916692
Provider Name (Legal Business Name): MS. ELEANOR AVAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2015
Last Update Date: 08/13/2023
Certification Date: 08/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 NEW GLOUCESTER RD
NORTH YARMOUTH ME
04097-6114
US

IV. Provider business mailing address

13 NEW GLOUCESTER RD
NORTH YARMOUTH ME
04097-6114
US

V. Phone/Fax

Practice location:
  • Phone: 781-266-8293
  • Fax:
Mailing address:
  • Phone: 781-266-8293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP3790
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: