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General NPI Number Information
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NPI Number | 1790801801
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Entity Type | Organization
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Legal Business Name | PROVIDENCE AUDIOLOGY
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Dates
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Enumeration Date | 03/21/2007
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Last Update Date | 10/25/2010
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Provider Practice Location Address
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Address Line | 1600 E JEFFERSON ST SUITE 202
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City | SEATTLE
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State | WA
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Zip | 98122-5698
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Country | US
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Telephone | 206-320-5687
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Fax | 206-320-8145
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Provider Business Mailing Address
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Address Line | 1600 E JEFFERSON ST SUITE 202
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City | SEATTLE
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State | WA
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Zip | 98122-5698
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Country | US
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Telephone | 206-320-5687
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Fax | 206-320-8145
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Authorized Official
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Title or Position | OWNER
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Name | SANDRA ELLIS
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Credential | AU.D., FAAA
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Telephone | 206-320-5687
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | LD00001067
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License Number State | WA
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