Provider Demographics
NPI:1104310218
Name:BAGNASCO, CAROLINE CULWELL (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:CULWELL
Last Name:BAGNASCO
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5209
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37802-5209
Mailing Address - Country:US
Mailing Address - Phone:865-982-3400
Mailing Address - Fax:865-238-2034
Practice Address - Street 1:1001 GRAND AVE UNIT 5
Practice Address - Street 2:
Practice Address - City:GLENWOOD SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81601-3642
Practice Address - Country:US
Practice Address - Phone:970-665-4744
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-21
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0004115235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1104310218Medicaid
TN6242OtherBOARD OF COMMUNICATION DISORDERS AND SCIENCES