Provider Demographics
NPI:1679954325
Name:PRINCE, AUDRIE
Entity Type:Individual
Prefix:
First Name:AUDRIE
Middle Name:
Last Name:PRINCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:GREENE
Mailing Address - State:ME
Mailing Address - Zip Code:04236
Mailing Address - Country:US
Mailing Address - Phone:207-689-4753
Mailing Address - Fax:
Practice Address - Street 1:141 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GREENE
Practice Address - State:ME
Practice Address - Zip Code:04236
Practice Address - Country:US
Practice Address - Phone:207-689-4753
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0A724224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant