Provider Demographics
NPI:1275651481
Name:WILKS, AUDRA MARIE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AUDRA
Middle Name:MARIE
Last Name:WILKS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 WAMPANOAG AVE
Mailing Address - Street 2:
Mailing Address - City:WESTERLY
Mailing Address - State:RI
Mailing Address - Zip Code:02891-2033
Mailing Address - Country:US
Mailing Address - Phone:401-596-1007
Mailing Address - Fax:
Practice Address - Street 1:1145 POQUONNOCK RD
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4620
Practice Address - Country:US
Practice Address - Phone:860-446-9960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002579235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist