Provider Demographics
NPI:1861168148
Name:MCMILLION, AUDREY ROSE (CF-SLP)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:ROSE
Last Name:MCMILLION
Suffix:
Gender:F
Credentials:CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 TAMWORTH CRK
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-9628
Mailing Address - Country:US
Mailing Address - Phone:870-403-8533
Mailing Address - Fax:
Practice Address - Street 1:CHILD DEVELOPMENT & REHABILITATION CENTER
Practice Address - Street 2:707 SW GAINES STREET
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239
Practice Address - Country:US
Practice Address - Phone:503-346-0640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-18
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR17200OtherOREGON BOARD OF EXAMINERS FOR SPEECH-LANGUAGE PATHOLOGY AND AUDIOLOGY