Provider Demographics
NPI:1932575610
Name:SOUTHBURY AUDIOLOGY LLC
Entity type:Organization
Organization Name:SOUTHBURY AUDIOLOGY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER OWNER LLC
Authorized Official - Prefix:DR
Authorized Official - First Name:CATHLEEN
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:ALEX
Authorized Official - Suffix:
Authorized Official - Credentials:AUD
Authorized Official - Phone:203-264-8201
Mailing Address - Street 1:2 POMPERAUG OFFICE PARK
Mailing Address - Street 2:SUITE 307
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-2288
Mailing Address - Country:US
Mailing Address - Phone:203-264-8201
Mailing Address - Fax:203-264-8201
Practice Address - Street 1:2 POMPERAUG OFFICE PARK
Practice Address - Street 2:SUITE 307
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-2288
Practice Address - Country:US
Practice Address - Phone:203-264-8201
Practice Address - Fax:203-264-8201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-17
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT109231HA2400X, 231HA2500X, 237600000X, 231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
No231HA2400XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology PractitionerGroup - Single Specialty
No231HA2500XSpeech, Language and Hearing Service ProvidersAudiologistAssistive Technology SupplierGroup - Single Specialty
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0123218OtherAETNA
CT4048864Medicaid
CT730000109CT01OtherANTHEM BCBS
CT4048674Medicaid
CTP442727OtherOXFORD
CT001376523-001OtherUNITED HEALTH CARE
CT724745OtherCONNECTICARE
CT4048674Medicaid