Provider Demographics
NPI:1306386792
Name:MAHLIE, AUDREY
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:MAHLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:BEFUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLBSW
Mailing Address - Street 1:717 N CENTER DR NW
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:MI
Mailing Address - Zip Code:49544-8215
Mailing Address - Country:US
Mailing Address - Phone:616-430-7791
Mailing Address - Fax:616-784-1281
Practice Address - Street 1:717 N CENTER DR NW
Practice Address - Street 2:
Practice Address - City:WALKER
Practice Address - State:MI
Practice Address - Zip Code:49544-8215
Practice Address - Country:US
Practice Address - Phone:616-430-7791
Practice Address - Fax:616-784-1281
Is Sole Proprietor?:No
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802085997104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker