Basic Information
| Provider Information | |||||||||
| NPI: | 1093341075 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONETTE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | THOMAS | ||||||||
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| Credential: | HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6558 JERICHO TPKE | ||||||||
| Address2: | |||||||||
| City: | COMMACK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117252901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314623572 | ||||||||
| FaxNumber: | 6314623569 | ||||||||
| Practice Location | |||||||||
| Address1: | 6558 JERICHO TPKE | ||||||||
| Address2: | |||||||||
| City: | COMMACK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117252901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314623572 | ||||||||
| FaxNumber: | 6314623569 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2020 | ||||||||
| LastUpdateDate: | 03/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 1400053738 | NY | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 14000053738 | 01 | NY | STATE LISENCE | OTHER |