Provider Demographics
NPI:1851708747
Name:GERVAIS, AUDRA ELIZABETH (CLC)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:ELIZABETH
Last Name:GERVAIS
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1667
Mailing Address - Street 2:
Mailing Address - City:HAVRE
Mailing Address - State:MT
Mailing Address - Zip Code:59501-1667
Mailing Address - Country:US
Mailing Address - Phone:406-380-2118
Mailing Address - Fax:
Practice Address - Street 1:1325 2ND AVE N
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3217
Practice Address - Country:US
Practice Address - Phone:406-380-2118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-13
Last Update Date:2014-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator