Provider Demographics
NPI:1013964915
Name:AUDREY B GREENWALD MS CCC PA
Entity Type:Organization
Organization Name:AUDREY B GREENWALD MS CCC PA
Other - Org Name:AUDREY B GREENWALD MS CCC PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MS
Authorized Official - First Name:AUDREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GREENWALD
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC
Authorized Official - Phone:5613-918-4444
Mailing Address - Street 1:160 NW 4TH ST
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-3826
Mailing Address - Country:US
Mailing Address - Phone:561-391-8444
Mailing Address - Fax:561-391-6823
Practice Address - Street 1:160 NW 4TH ST
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33432-3826
Practice Address - Country:US
Practice Address - Phone:561-391-8444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ3827302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL882652800Medicaid