Provider Demographics
NPI:1902132004
Name:AVIZIENIS, DAIVA LIUCIJA
Entity Type:Individual
Prefix:
First Name:DAIVA
Middle Name:LIUCIJA
Last Name:AVIZIENIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 E MULBERRY ST APT 1
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-2691
Mailing Address - Country:US
Mailing Address - Phone:708-334-1154
Mailing Address - Fax:
Practice Address - Street 1:108 W MARKET ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3918
Practice Address - Country:US
Practice Address - Phone:309-827-5351
Practice Address - Fax:309-829-6808
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health