Provider Demographics
NPI:1093804106
Name:PRINCE, AUDRA RENAE (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:RENAE
Last Name:PRINCE
Suffix:
Gender:F
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E MAIN ST
Mailing Address - Street 2:SUITE 3
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-5247
Mailing Address - Country:US
Mailing Address - Phone:479-498-6700
Mailing Address - Fax:
Practice Address - Street 1:701 E MAIN ST
Practice Address - Street 2:SUITE 3
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-5247
Practice Address - Country:US
Practice Address - Phone:479-498-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2014-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2060C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical