=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629354014
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEELA A CLEARY AUD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/29/2011
-----------------------------------------------------
Last Update Date | 05/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 CRANBERRY CT
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17046-8120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-394-4058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 374 NORTHWOOD DR
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17042-8923
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-394-4058
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | AT006230
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------