Healthcare Provider Details

I. General information

NPI: 1629169800
Provider Name (Legal Business Name): MICHELLE WALLER M.A.CCC-A
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. MICHELLE COPPOLA

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 08/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 EAST MAIN STREET STE. 17
BAYSHORE NY
11706
US

IV. Provider business mailing address

251 LYMAN RD
EAST PATCHOGUE NY
11772-6249
US

V. Phone/Fax

Practice location:
  • Phone: 631-665-6922
  • Fax:
Mailing address:
  • Phone: 631-286-9366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number002098-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: