Provider Demographics
NPI:1801492426
Name:SPROUSE, AUDWIN SR
Entity type:Individual
Prefix:
First Name:AUDWIN
Middle Name:
Last Name:SPROUSE
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 DELTA BLUFF CV
Mailing Address - Street 2:
Mailing Address - City:WALLS
Mailing Address - State:MS
Mailing Address - Zip Code:38680-4400
Mailing Address - Country:US
Mailing Address - Phone:662-510-4660
Mailing Address - Fax:
Practice Address - Street 1:8900 DELTA BLUFF CV
Practice Address - Street 2:
Practice Address - City:WALLS
Practice Address - State:MS
Practice Address - Zip Code:38680-4400
Practice Address - Country:US
Practice Address - Phone:662-510-4660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)