Healthcare Provider Details

I. General information

NPI: 1659571875
Provider Name (Legal Business Name): LESLEY SEGAL AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: VINEYARD AUDIOLOGY CCC/A

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 INDIAN HILL ROAD
WEST TISBURY MA
02575
US

IV. Provider business mailing address

PO BOX 2095
VINEYARD HAVEN MA
02568-0915
US

V. Phone/Fax

Practice location:
  • Phone: 508-696-4600
  • Fax: 508-696-3017
Mailing address:
  • Phone: 508-696-4600
  • Fax: 508-696-3017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number620
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: