Provider Demographics
NPI:1417386327
Name:MACLEOD, AUDREY DIANE
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:DIANE
Last Name:MACLEOD
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 1:7 FREDDY RD
Mailing Address - Street 2:
Mailing Address - City:BILLERICA
Mailing Address - State:MA
Mailing Address - Zip Code:01821-2204
Mailing Address - Country:US
Mailing Address - Phone:978-761-3694
Mailing Address - Fax:
Practice Address - Street 1:80 ANDOVER ST
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-5606
Practice Address - Country:US
Practice Address - Phone:978-470-3434
Practice Address - Fax:978-749-2955
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1793224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant