Provider Demographics
NPI:1912388000
Name:CARLSON, AUDREY (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:MS
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:VAN ACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:326 CHARDONNAY AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PROSSER
Mailing Address - State:WA
Mailing Address - Zip Code:99350-9515
Mailing Address - Country:US
Mailing Address - Phone:509-786-6626
Mailing Address - Fax:
Practice Address - Street 1:326 CHARDONNAY AVE STE 1
Practice Address - Street 2:
Practice Address - City:PROSSER
Practice Address - State:WA
Practice Address - Zip Code:99350-9515
Practice Address - Country:US
Practice Address - Phone:509-786-6626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist