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NPI Code Detail

MEDICARE: AUDREY MAHLSTEDT MA CCC-SLP

MEDICARE: AUDREY MAHLSTEDT MA CCC-SLP
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior Analyst1-16-21486CA
2235Z00000XSpeech-Language Pathologist18299CA

General Provider Information

NPI Number : 1164086187
Entity Type Code : Individual
Provider Name (Legal Business Name) : AUDREY MAHLSTEDT MA CCC-SLP
Provider Business Mailing Address
First Line : 2186 FRANCISCO AVE
Second Line :
City : SANTA ROSA
State : CA
Zip : 95403-8173
Country : US
Telephone Number : 760-390-5450
Fax Number :
Provider Business Practice Location Address
First Line : 7165 BURTON AVE
Second Line :
City : ROHNERT PARK
State : CA
Zip : 94928-3316
Country : US
Telephone Number : 707-792-4700
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/25/2019
Last Update Date : 04/25/2019

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