Provider Demographics
NPI:1114142684
Name:URBAN, AUDREY M (BSED)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:M
Last Name:URBAN
Suffix:
Gender:F
Credentials:BSED
Other - Prefix:MS
Other - First Name:AUDREY
Other - Middle Name:M
Other - Last Name:GRINSTEINNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 13TH AVE W
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4879
Mailing Address - Country:US
Mailing Address - Phone:701-227-7469
Mailing Address - Fax:
Practice Address - Street 1:300 13TH AVE W
Practice Address - Street 2:SUITE 1
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4879
Practice Address - Country:US
Practice Address - Phone:701-227-7469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54523Medicaid