Provider Demographics
NPI:1104414408
Name:HOLMES, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:HOLMES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:HARRINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2522 STOCKBRIDGE SQ SW
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32962-4215
Mailing Address - Country:US
Mailing Address - Phone:616-389-4913
Mailing Address - Fax:
Practice Address - Street 1:1755 37TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-4812
Practice Address - Country:US
Practice Address - Phone:772-567-2443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA17263235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14075195OtherASHA NUMBER