Provider Demographics
NPI:1679788707
Name:RUBIN, AUDREY S (MS,CCC)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:S
Last Name:RUBIN
Suffix:
Gender:F
Credentials:MS,CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 ROSE GLEN DR
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-4704
Mailing Address - Country:US
Mailing Address - Phone:978-475-6335
Mailing Address - Fax:978-686-0456
Practice Address - Street 1:12 ROSE GLEN DR
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MA
Practice Address - Zip Code:01810-4704
Practice Address - Country:US
Practice Address - Phone:978-475-6335
Practice Address - Fax:978-686-0456
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1229235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0330841Medicaid