Basic Information
| Provider Information | |||||||||
| NPI: | 1750804282 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVERSA | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17 COOPER ST APT 3 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021132284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7814627885 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3 BRAZIER LN | ||||||||
| Address2: | |||||||||
| City: | KENNEBUNK | ||||||||
| State: | ME | ||||||||
| PostalCode: | 040437095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079853030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2017 | ||||||||
| LastUpdateDate: | 07/17/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.