Provider Demographics
NPI:1932979267
Name:SQUIRE, AUDRA MARIE
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:MARIE
Last Name:SQUIRE
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 1:1505 FORT CLARKE BLVD APT 18201
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-9158
Mailing Address - Country:US
Mailing Address - Phone:352-250-6688
Mailing Address - Fax:
Practice Address - Street 1:4907 NW 43RD ST STE C
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-2007
Practice Address - Country:US
Practice Address - Phone:352-372-0047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician