Provider Demographics
NPI:1295794311
Name:BUBENHEIMER, LORI LEAH (AUD)
Entity type:Individual
Prefix:MRS
First Name:LORI
Middle Name:LEAH
Last Name:BUBENHEIMER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:MS
Other - First Name:LORI
Other - Middle Name:LEAH
Other - Last Name:ARONOVICI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:11945 SAN JOSE BLVD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223-1613
Mailing Address - Country:US
Mailing Address - Phone:904-396-1725
Mailing Address - Fax:904-396-4893
Practice Address - Street 1:4203 BELFORT RD STE 340
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1409
Practice Address - Country:US
Practice Address - Phone:904-880-0911
Practice Address - Fax:904-880-9388
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY727231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104898500Medicaid
FL6004521-00Medicaid
FLP00737616Medicare PIN