Provider Demographics
NPI:1891379921
Name:WILLIAMS, AUDREY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5208 OLD LANTERN WAY
Mailing Address - Street 2:
Mailing Address - City:CHOCTAW
Mailing Address - State:OK
Mailing Address - Zip Code:73020-9745
Mailing Address - Country:US
Mailing Address - Phone:918-348-4605
Mailing Address - Fax:
Practice Address - Street 1:5208 OLD LANTERN WAY
Practice Address - Street 2:
Practice Address - City:CHOCTAW
Practice Address - State:OK
Practice Address - Zip Code:73020-9745
Practice Address - Country:US
Practice Address - Phone:918-348-4605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMSLP7344235Z00000X
FLSA13552235Z00000X
OK5519235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist