Healthcare Provider Details

I. General information

NPI: 1932575610
Provider Name (Legal Business Name): SOUTHBURY AUDIOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2015
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 POMPERAUG OFFICE PARK SUITE 307
SOUTHBURY CT
06488-2288
US

IV. Provider business mailing address

2 POMPERAUG OFFICE PARK SUITE 307
SOUTHBURY CT
06488-2288
US

V. Phone/Fax

Practice location:
  • Phone: 203-264-8201
  • Fax: 203-264-8201
Mailing address:
  • Phone: 203-264-8201
  • Fax: 203-264-8201

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number109
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code231HA2400X
TaxonomyAssistive Technology Practitioner Audiologist
License Number109
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code231HA2500X
TaxonomyAssistive Technology Supplier Audiologist
License Number109
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number109
License Number StateCT

VIII. Authorized Official

Name: DR. CATHLEEN ANNE ALEX
Title or Position: SOLE MEMBER OWNER LLC
Credential: AUD
Phone: 203-264-8201