Provider Demographics
NPI:1306101258
Name:ALBA, AUDREY RENEE (SLP)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:RENEE
Last Name:ALBA
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 MONTANA AVE STE C
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-5654
Mailing Address - Country:US
Mailing Address - Phone:915-209-0014
Mailing Address - Fax:915-792-0029
Practice Address - Street 1:1401 MONTANA AVE STE C
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-5654
Practice Address - Country:US
Practice Address - Phone:915-209-0014
Practice Address - Fax:915-792-0029
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-06
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36872235Z00000X
TX111433235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX207164901Medicaid
TX149984001Medicaid
TX456606Medicare PIN
TX149984001Medicaid