Provider Demographics
NPI:1720213507
Name:WARDLAW, AUDREY BURKE (LPC)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:BURKE
Last Name:WARDLAW
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 SCHOMBURG RD
Mailing Address - Street 2:#412
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-1505
Mailing Address - Country:US
Mailing Address - Phone:706-358-7480
Mailing Address - Fax:
Practice Address - Street 1:6900 SCHOMBURG RD
Practice Address - Street 2:#412
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31909-1505
Practice Address - Country:US
Practice Address - Phone:706-358-7480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-21
Last Update Date:2009-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC004528101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional