MEDICARE: ELIZABETH AVIS MS CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	167266	KY

General Provider Information

NPI Number	:	1801324272
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH AVIS MS CCC-SLP

Provider Business Mailing Address
First Line	:	103 LINDEN AVE
Second Line	:
City	:	BARDSTOWN
State	:	KY
Zip	:	40004-6804
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2625 BARDSTOWN RD
Second Line	:
City	:	ST CATHARINE
State	:	KY
Zip	:	40061-9435
Country	:	US
Telephone Number	:	859-336-3974
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/30/2017
Last Update Date	:	05/30/2017

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Directions to “ ELIZABETH AVIS MS CCC-SLP” Practice Location

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