Provider Demographics
NPI:1508371378
Name:ROWE, AUDRA MARIE
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:MARIE
Last Name:ROWE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:AUDRA
Other - Middle Name:MARIE
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCPC
Mailing Address - Street 1:1350 W 103RD ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-2302
Mailing Address - Country:US
Mailing Address - Phone:773-881-1711
Mailing Address - Fax:
Practice Address - Street 1:1350 W 103RD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60643-2302
Practice Address - Country:US
Practice Address - Phone:773-881-1711
Practice Address - Fax:773-881-3379
Is Sole Proprietor?:No
Enumeration Date:2017-12-02
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180010984101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional