Healthcare Provider Details

I. General information

NPI: 1508038365
Provider Name (Legal Business Name): MSU CENTER FOR AUDIOLOGY AND SPEECH LANGUAGE PATHOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSU CENTER FOR AUDIOLOGY AND SPEECH LANGUAGE PATHOLOGY 1515 BROAD STREET
BLOOMFIELD NJ
07003
US

IV. Provider business mailing address

MSU CENTER FOR AUDIOLOGY AND SPEECH LANGUAGE PATHOLOGY 1515 BROAD STREET
BLOOMFIELD NJ
07003
US

V. Phone/Fax

Practice location:
  • Phone: 973-655-3934
  • Fax: 973-655-7752
Mailing address:
  • Phone: 973-655-3934
  • Fax: 973-655-7752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MS. DONNA MCMONAGLE
Title or Position: VICE PRESIDENT FOR FINANCE AND TREA
Credential:
Phone: 973-655-5105