Basic Information
| Provider Information | |||||||||
| NPI: | 1386970101 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASSON | ||||||||
| FirstName: | ROBERTA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHULTZ | ||||||||
| OtherFirstName: | ROBERTA | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 21 EVERETT ROAD EXT. | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184351400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21 EVERETT ROAD EXT. | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5184351400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2009 | ||||||||
| LastUpdateDate: | 10/29/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 150 | MA | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 237700000X | 14000014850 | NY | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.