Provider Demographics
NPI:1629209846
Name:MATTY, AUDREY I (SLP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:I
Last Name:MATTY
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 1:3040 N WICKHAM RD
Mailing Address - Street 2:SUITE 7
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-2369
Mailing Address - Country:US
Mailing Address - Phone:321-255-9546
Mailing Address - Fax:321-255-4690
Practice Address - Street 1:3040 N WICKHAM RD
Practice Address - Street 2:SUITE 7
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-2369
Practice Address - Country:US
Practice Address - Phone:321-255-9546
Practice Address - Fax:321-255-4690
Is Sole Proprietor?:No
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5470235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist