Provider Demographics
NPI:1912659392
Name:TOURVILLE, AUDRA LEEANN
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:LEEANN
Last Name:TOURVILLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12554 SULPHUR BANK MINE RD
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95423-9666
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39201 STATE ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1437
Practice Address - Country:US
Practice Address - Phone:866-206-2008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician