Healthcare Provider Details

I. General information

NPI: 1952628703
Provider Name (Legal Business Name): SUSAN REVEAL-OTTONE AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 W PADONIA RD STE C245
TIMONIUM MD
21093-2237
US

IV. Provider business mailing address

215 SHUMAN BLVD STE 401
NAPERVILLE IL
60563-8458
US

V. Phone/Fax

Practice location:
  • Phone: 410-252-9270
  • Fax: 410-252-9270
Mailing address:
  • Phone: 630-303-5380
  • Fax: 978-313-6824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License Number00973
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: