Basic Information
| Provider Information | |||||||||
| NPI: | 1285670869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONNA | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | JANET | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., CCC-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCCALLUM | ||||||||
| OtherFirstName: | MICHELLE | ||||||||
| OtherMiddleName: | DONNA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 792 FLANDERS RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064891307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606219329 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 950 CAMPBELL AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065162770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039325711 | ||||||||
| FaxNumber: | 2039373872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 000305 | CT | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.