Provider Demographics
NPI:1194700922
Name:DETHLOFF, CARVER GRAY (AUD)
Entity type:Individual
Prefix:
First Name:CARVER
Middle Name:GRAY
Last Name:DETHLOFF
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 1:11 RACETRACK RD NE STE E4
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-1867
Mailing Address - Country:US
Mailing Address - Phone:850-315-4141
Mailing Address - Fax:850-226-8242
Practice Address - Street 1:11 RACETRACK RD NE STE E4
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1867
Practice Address - Country:US
Practice Address - Phone:850-315-4141
Practice Address - Fax:850-226-8242
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1018231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS9298OtherBCBS
FL600389300Medicaid
FLP79979Medicare UPIN