Provider Demographics
NPI:1154821346
Name:VANMATRE, AUDRA NICOLE
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:NICOLE
Last Name:VANMATRE
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 1:6400 W 110TH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1585
Mailing Address - Country:US
Mailing Address - Phone:816-607-1775
Mailing Address - Fax:
Practice Address - Street 1:7223 W 95TH ST STE 220
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66212-6195
Practice Address - Country:US
Practice Address - Phone:913-346-1516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
KS03779101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171M00000XOther Service ProvidersCase Manager/Care Coordinator