Provider Demographics
NPI:1295300515
Name:ROSE, AUDREY LELA (MA, CF-SLP)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:LELA
Last Name:ROSE
Suffix:
Gender:F
Credentials:MA, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 WOBURN LN
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-2138
Mailing Address - Country:US
Mailing Address - Phone:630-750-0246
Mailing Address - Fax:
Practice Address - Street 1:248 WOBURN LN
Practice Address - Street 2:
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-2138
Practice Address - Country:US
Practice Address - Phone:630-750-0246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-20
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program