Basic Information
Provider Information | |||||||||
NPI: | 1811312515 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOBILE AUDIOLOGY ASSOCIATES, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 CROSSING BLVD | ||||||||
Address2: | SUITE 300 | ||||||||
City: | FRAMINGHAM | ||||||||
State: | MA | ||||||||
PostalCode: | 017025555 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6179646681 | ||||||||
FaxNumber: | 3396862561 | ||||||||
Practice Location | |||||||||
Address1: | 6700 ALEXANDER BELL DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | COLUMBIA | ||||||||
State: | MD | ||||||||
PostalCode: | 210462122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8889646681 | ||||||||
FaxNumber: | 8886620859 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/04/2014 | ||||||||
LastUpdateDate: | 04/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TASSE | ||||||||
AuthorizedOfficialFirstName: | LAURA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6179646681 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | MOBILE AUDIOLOGY ASSOCIATES, PC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | AUD | ||||||||
NPICertificationDate: | 04/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |   |
ID Information
ID | Type | State | Issuer | Description | 214341100 | 05 | MD |   | MEDICAID | 074850800 | 05 | DC |   | MEDICAID |