Provider Demographics
NPI:1114806569
Name:BALES, AUDREY GRACE
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:GRACE
Last Name:BALES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:GRACE
Other - Last Name:TEPEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5105 DAWSON DR APT C
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63090-3817
Mailing Address - Country:US
Mailing Address - Phone:618-946-4344
Mailing Address - Fax:
Practice Address - Street 1:840 W PRIDE DR
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-1207
Practice Address - Country:US
Practice Address - Phone:636-390-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-29
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020021641225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist