Basic Information
| Provider Information | |||||||||
| NPI: | 1811231103 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANNAN | ||||||||
| FirstName: | CHELSEA | ||||||||
| MiddleName: | JULIANO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AUD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DIECK | ||||||||
| OtherFirstName: | CHELSEA | ||||||||
| OtherMiddleName: | JULIANO | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | AUD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1222 S PATTERSON BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454022642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374962620 | ||||||||
| FaxNumber: | 9374248518 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 S PATTERSON BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454022642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374962620 | ||||||||
| FaxNumber: | 9374248518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2012 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | A.01820 | OH | Y | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
No ID Information.