Provider Demographics
NPI:1225050289
Name:TYLER, AUDREY SUSAN
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:SUSAN
Last Name:TYLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:SUSAN
Other - Last Name:TYLER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS,CCC/SLP
Mailing Address - Street 1:420 LAKEBRIDGE PLAZA DR
Mailing Address - Street 2:APARTMENT 1005
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1219 DUNN AVE
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2405
Practice Address - Country:US
Practice Address - Phone:386-255-4568
Practice Address - Fax:386-258-7677
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA1267235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist