Basic Information
| Provider Information | |||||||||
| NPI: | 1427364876 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTINGLY | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | MELISSA | ||||||||
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| Credential: | AU.D.,CCC-A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 W HALF DAY RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | BUFFALO GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600896591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478683435 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 W HALF DAY RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | BUFFALO GROVE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600896591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478683435 | ||||||||
| FaxNumber: | 8478595885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2010 | ||||||||
| LastUpdateDate: | 11/18/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | 147-000978 | IL | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.