Basic Information
| Provider Information | |||||||||
| NPI: | 1740551605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AHLBERG | ||||||||
| FirstName: | KANDICE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AUD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WESTPHAL | ||||||||
| OtherFirstName: | KANDICE | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 720 W 34TH ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123467600 | ||||||||
| FaxNumber: | 5123467603 | ||||||||
| Practice Location | |||||||||
| Address1: | 720 W 34TH ST STE 110 | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787051202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123467600 | ||||||||
| FaxNumber: | 5123467603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2012 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 81218 | TX | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 231H00000X | 81218 | TX | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 200462350A | 05 | OK | MEDICAID |