Basic Information
| Provider Information | |||||||||
| NPI: | 1912039942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BAJUSCAK | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | AU.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9250 N 3RD ST | ||||||||
| Address2: | SUITE 4010 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850202437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026336348 | ||||||||
| FaxNumber: | 6026333841 | ||||||||
| Practice Location | |||||||||
| Address1: | 515 W BUCKEYE RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850032647 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022580298 | ||||||||
| FaxNumber: | 6022548401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/13/2007 | ||||||||
| LastUpdateDate: | 02/07/2013 | ||||||||
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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 | 9275 | NC | N | Speech, Language and Hearing Service Providers | Audiologist | 231H00000X | DA4099 | AZ | Y | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 86-0783428 | 01 | AZ | TAX-ID | OTHER |