Basic Information
| Provider Information | |||||||||
| NPI: | 1396828562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MONCAVAGE | ||||||||
| FirstName: | CHRISTI | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 2ND ST | ||||||||
| Address2: | CENTENNIAL HALL | ||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178151301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703895380 | ||||||||
| FaxNumber: | 5703895022 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 E 2ND ST | ||||||||
| Address2: | CENTENNIAL HALL | ||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178151301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703895380 | ||||||||
| FaxNumber: | 5703895022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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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 | AT000965L | PA | Y | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | AT000965L | PA | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 231HA2500X | AT000965L | PA | N | Speech, Language and Hearing Service Providers | Audiologist | Assistive Technology Supplier | 231HA2400X | AT000965L | PA | N | Speech, Language and Hearing Service Providers | Audiologist | Assistive Technology Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 1018694600001 | 05 | PA | MEDICAID |