Provider Demographics
NPI:1497884704
Name:BERK, AUDREY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:BERK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5104 JEANNINE CT
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32807-1366
Mailing Address - Country:US
Mailing Address - Phone:941-914-3181
Mailing Address - Fax:
Practice Address - Street 1:11602 LAKE UNDERHILL RD
Practice Address - Street 2:SUITE 129
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32825-4458
Practice Address - Country:US
Practice Address - Phone:407-277-5400
Practice Address - Fax:321-281-4942
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-04
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8920235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8919992Medicaid