Provider Demographics
NPI:1962478156
Name:BACON, SALLY ANN (AUD)
Entity Type:Individual
Prefix:MS
First Name:SALLY
Middle Name:ANN
Last Name:BACON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3599 BIG RIDGE RD.
Mailing Address - Street 2:
Mailing Address - City:SPENCERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14559
Mailing Address - Country:US
Mailing Address - Phone:585-352-2440
Mailing Address - Fax:
Practice Address - Street 1:3599 BIG RIDGE RD
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-1709
Practice Address - Country:US
Practice Address - Phone:585-352-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP85480Medicare UPIN
NYDD4937Medicare ID - Type UnspecifiedMEDICARE INDIVIDUAL NUMBE