Provider Demographics
NPI:1336181304
Name:SMITH, AUDRA DULAC (MA, CCC-A)
Entity Type:Individual
Prefix:MRS
First Name:AUDRA
Middle Name:DULAC
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 POVERTY LN
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-2708
Mailing Address - Country:US
Mailing Address - Phone:603-448-0734
Mailing Address - Fax:
Practice Address - Street 1:215 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHITE RIVER JUNCTION
Practice Address - State:VT
Practice Address - Zip Code:05009-0001
Practice Address - Country:US
Practice Address - Phone:802-295-9363
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHA405231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
09136171OtherASHA MEMBER #
NHA405OtherNHSTATE AUDIOLOGY LICENSE