=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144881947
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN LYNN AVERY-MCDANIEL BCABA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2019
-----------------------------------------------------
Last Update Date | 06/24/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 785 KING GEORGE BLVD STE 103
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31419-8376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-252-0040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 578 LEE RD
-----------------------------------------------------
City | PEMBROKE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31321-8329
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-325-2530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 0-19-9996
-----------------------------------------------------
License Number State |
-----------------------------------------------------