Provider Demographics
NPI:1194342030
Name:BANNER, CARLY HINTON (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:HINTON
Last Name:BANNER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:MARIE
Other - Last Name:HINTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 912
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:CO
Mailing Address - Zip Code:80549-0912
Mailing Address - Country:US
Mailing Address - Phone:719-480-2932
Mailing Address - Fax:
Practice Address - Street 1:4126 HAYES AVE
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:CO
Practice Address - Zip Code:80549
Practice Address - Country:US
Practice Address - Phone:719-480-2932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-26
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYSP-1030235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY732F717AFBMedicaid