Provider Demographics
NPI:1063406726
Name:BENNETT, CAROLYN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 CUMBERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-6004
Mailing Address - Country:US
Mailing Address - Phone:704-408-1730
Mailing Address - Fax:
Practice Address - Street 1:200 YALE AVE
Practice Address - Street 2:
Practice Address - City:MORTON
Practice Address - State:PA
Practice Address - Zip Code:19070-1918
Practice Address - Country:US
Practice Address - Phone:704-408-1730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-08
Last Update Date:2009-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL009422235Z00000X
PAAT006098231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAAT006098OtherCOMMONWEALTH OF PENNSYLVANIA
PASL009422OtherCOMMONWEALTH OF PENNSYLVANIA