Provider Demographics
NPI:1568920023
Name:POWELL, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:POWELL
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 1:63 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-7417
Mailing Address - Country:US
Mailing Address - Phone:480-472-0200
Mailing Address - Fax:
Practice Address - Street 1:63 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-7417
Practice Address - Country:US
Practice Address - Phone:480-472-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA149342355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Multi-Specialty