Provider Demographics
NPI:1366722514
Name:AVERA, KELLI SUZANNE NABORS (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:SUZANNE NABORS
Last Name:AVERA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:KELLI
Other - Middle Name:SUZANNE
Other - Last Name:NABORS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:1040 MALLARD CT
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-3235
Mailing Address - Country:US
Mailing Address - Phone:706-247-5469
Mailing Address - Fax:
Practice Address - Street 1:1040 MALLARD CT
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-3235
Practice Address - Country:US
Practice Address - Phone:706-247-5469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005835235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist