=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689899874
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL AUDIOLOGY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2007
-----------------------------------------------------
Last Update Date | 09/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 800 AUSTIN ST STE 360E STE 256 EAST
-----------------------------------------------------
City | EVANSTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60202-3454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-674-8761
-----------------------------------------------------
Fax | 847-674-8764
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 43
-----------------------------------------------------
City | SKOKIE
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60076-0043
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 847-674-8761
-----------------------------------------------------
Fax | 847-674-8764
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | DAVID ANTHONY KLODD
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 847-924-2931
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 231H00000X
-----------------------------------------------------
Taxonomy Name | Audiologist
-----------------------------------------------------
License Number | 14700269
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------