Provider Demographics
NPI:1710049762
Name:FORMICHETTI, TRISHA DAWN (AUD)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:DAWN
Last Name:FORMICHETTI
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:LYN
Other - Last Name:FORMICHETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUD
Mailing Address - Street 1:900 NW 13TH ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-2335
Mailing Address - Country:US
Mailing Address - Phone:561-391-3333
Mailing Address - Fax:561-391-5618
Practice Address - Street 1:900 NW 13TH ST
Practice Address - Street 2:SUITE 206
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-2335
Practice Address - Country:US
Practice Address - Phone:561-391-3333
Practice Address - Fax:561-391-5618
Is Sole Proprietor?:No
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1217231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU2437ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER