Provider Demographics
NPI:1558532408
Name:MEHTA, MALA RUSHABH (MA CCCA)
Entity Type:Individual
Prefix:
First Name:MALA
Middle Name:RUSHABH
Last Name:MEHTA
Suffix:
Gender:F
Credentials:MA CCCA
Other - Prefix:
Other - First Name:MALA
Other - Middle Name:HARNISH
Other - Last Name:MEHTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1211 HAMBURG TPKE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-5043
Mailing Address - Country:US
Mailing Address - Phone:973-633-0808
Mailing Address - Fax:973-633-8811
Practice Address - Street 1:1211 HAMBURG TPKE
Practice Address - Street 2:SUITE 205
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-5043
Practice Address - Country:US
Practice Address - Phone:973-633-0808
Practice Address - Fax:973-633-8811
Is Sole Proprietor?:No
Enumeration Date:2008-03-19
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YA00046100231H00000X
NJ25MG00089400237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ129717NEWMedicare PIN