Provider Demographics
NPI:1770030694
Name:DURAN, AUDREY
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:DURAN
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 1:600 E BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:OH
Mailing Address - Zip Code:45030-1323
Mailing Address - Country:US
Mailing Address - Phone:513-367-4161
Mailing Address - Fax:
Practice Address - Street 1:600 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:OH
Practice Address - Zip Code:45030-1323
Practice Address - Country:US
Practice Address - Phone:513-367-4161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-08
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21229331103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool