1457492050 NPI number — MICHELLE SUSAN BASALYGA MA CCC-SLP

Table of content: MICHELLE SUSAN BASALYGA MA CCC-SLP (NPI 1457492050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457492050 NPI number — MICHELLE SUSAN BASALYGA MA CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BASALYGA
Provider First Name:
MICHELLE
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457492050
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 UPPER KNAPP RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARKS SUMMIT
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
18411-2086
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-587-9982
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
242 NOBLE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLARKS SUMMIT
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
18411-9406
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-587-5101
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SL002711L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 11226913 . This is a "CAQH ID" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: SL002711L . This is a "STATE LICRNSE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 2601606 . This is a "PROVIDER #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 758735 . This is a "PROVIDER #" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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