Basic Information
Provider Information | |||||||||
NPI: | 1245524735 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GOTAY | ||||||||
FirstName: | MICHELLE | ||||||||
MiddleName: | RENEE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SCOFIELD | ||||||||
OtherFirstName: | MICHELLE | ||||||||
OtherMiddleName: | RENEE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 171 GRANDVIEW AVE STE 201 | ||||||||
Address2: |   | ||||||||
City: | WATERBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 067082520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2035784630 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 171 GRANDVIEW AVE STE 201 | ||||||||
Address2: |   | ||||||||
City: | WATERBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 067082520 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2035784630 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2011 | ||||||||
LastUpdateDate: | 06/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 231 | CT | N |   | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |   | 231H00000X | 231 | CT | Y |   | Speech, Language and Hearing Service Providers | Audiologist |   |
No ID Information.