Provider Demographics
NPI:1982897195
Name:DESPAIN, AUDREY LYNN (SLP)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:LYNN
Last Name:DESPAIN
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 1:4601 BEGONIA ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-2133
Mailing Address - Country:US
Mailing Address - Phone:361-362-4122
Mailing Address - Fax:361-433-7800
Practice Address - Street 1:4601 BEGONIA ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-2133
Practice Address - Country:US
Practice Address - Phone:361-362-4122
Practice Address - Fax:361-433-7800
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110259235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX164704201Medicaid
TX454843Medicare Oscar/Certification