Basic Information
| Provider Information | |||||||||
| NPI: | 1811031479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PILTCH | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | AUDIOLOGIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1310 COMMERCE ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949541469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077787862 | ||||||||
| FaxNumber: | 7077780969 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 LYNCH CREEK WY | ||||||||
| Address2: | SUITE 9A | ||||||||
| City: | PETALUMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077620103 | ||||||||
| FaxNumber: | 7077625174 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 07/22/2010 | ||||||||
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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 | AU897 | CA | Y | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | HA3511 | CA | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | AU 897 | 01 | CA | LICENSE NO. | OTHER | HA3511 | 01 | CA | STATE OF CALIFORNIA HEARING AID LICENSING BOARD | OTHER | HA0035110 | 05 | CA | MEDICAID |