Provider Demographics
NPI:1598062291
Name:MACCOMER, AUDREY (SLP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:MACCOMER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 E NORTH BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-4114
Mailing Address - Country:US
Mailing Address - Phone:614-261-5437
Mailing Address - Fax:614-263-5445
Practice Address - Street 1:5603 INDIANOLA AVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:OH
Practice Address - Zip Code:43085
Practice Address - Country:US
Practice Address - Phone:614-296-4431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-16
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP-9841235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist