Provider Demographics
NPI:1609447887
Name:LARCOMB, AUDREY (SLP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:LARCOMB
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 1:6572 RIVER PARK DR STE 101
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2214
Mailing Address - Country:US
Mailing Address - Phone:678-262-1833
Mailing Address - Fax:
Practice Address - Street 1:6572 RIVER PARK DR STE 101
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2214
Practice Address - Country:US
Practice Address - Phone:678-262-1833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET003287235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPCET003287OtherSLP STATE LICENSE