Provider Demographics
NPI:1164086187
Name:MAHLSTEDT, AUDREY (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:MAHLSTEDT
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:HARRINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:2186 FRANCISCO AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-8173
Mailing Address - Country:US
Mailing Address - Phone:760-390-5450
Mailing Address - Fax:
Practice Address - Street 1:7165 BURTON AVE
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-3316
Practice Address - Country:US
Practice Address - Phone:707-792-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-16-21486103K00000X
CA18299235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst