Basic Information
| Provider Information | |||||||||
| NPI: | 1104942002 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOUBIN | ||||||||
| FirstName: | FELICIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1222 S PATTERSON BLVD | ||||||||
| Address2: | STE 400 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454022642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374962620 | ||||||||
| FaxNumber: | 9374248518 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 S PATTERSON BLVD | ||||||||
| Address2: | STE 400 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454022642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374962620 | ||||||||
| FaxNumber: | 9374248518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2007 | ||||||||
| LastUpdateDate: | 01/09/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | A0531 | OH | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 000000321647 | 01 | ANTHEM | OTHER |