Healthcare Provider Details

I. General information

NPI: 1013964915
Provider Name (Legal Business Name): AUDREY B GREENWALD MS CCC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 NW 4TH ST
BOCA RATON FL
33432-3826
US

IV. Provider business mailing address

160 NW 4TH ST
BOCA RATON FL
33432-3826
US

V. Phone/Fax

Practice location:
  • Phone: 561-391-8444
  • Fax:
Mailing address:
  • Phone: 561-391-8444
  • Fax: 561-391-6823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberSZ3827
License Number StateFL

VIII. Authorized Official

Name: MS. AUDREY GREENWALD
Title or Position: SPEECH LANGUAGE PATHOLOGIST
Credential: MS CCC
Phone: 56139184444