Provider Demographics
NPI:1508225459
Name:TATE, AUDREY JEAN (LPC, AT, CDCA)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:JEAN
Last Name:TATE
Suffix:
Gender:F
Credentials:LPC, AT, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17852 CANNON AVE # UP
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-2206
Mailing Address - Country:US
Mailing Address - Phone:216-501-0799
Mailing Address - Fax:
Practice Address - Street 1:347 MIDWAY BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:ELYRIA
Practice Address - State:OH
Practice Address - Zip Code:44035-9006
Practice Address - Country:US
Practice Address - Phone:440-324-5701
Practice Address - Fax:440-324-9978
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-21
Last Update Date:2016-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC 1300788101Y00000X
OH151783101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)