Basic Information
| Provider Information | |||||||||
| NPI: | 1205508652 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DURIVAGE | ||||||||
| FirstName: | EMMA | ||||||||
| MiddleName: | |||||||||
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| Credential: | AUD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 N COMMONS DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605047940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303035380 | ||||||||
| FaxNumber: | 6303035385 | ||||||||
| Practice Location | |||||||||
| Address1: | 8300 N HAYDEN RD STE E102 | ||||||||
| Address2: | |||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852582589 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4803052033 | ||||||||
| FaxNumber: | 4803052034 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2021 | ||||||||
| LastUpdateDate: | 10/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | DA13444 | AZ | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | DA13444 | 01 | AZ | AZ STATE DISPENSING LICENSE | OTHER |