Provider Demographics
NPI:1760505085
Name:QUALLEY, MICHAEL D (AUD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:QUALLEY
Suffix:
Gender:M
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4747-8 NESCONSET HWY
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-2878
Mailing Address - Country:US
Mailing Address - Phone:631-331-6455
Mailing Address - Fax:
Practice Address - Street 1:4747-8 NESCONSET HWY
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-2878
Practice Address - Country:US
Practice Address - Phone:631-331-6455
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001010231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYM03441Medicare ID - Type Unspecified