Provider Demographics
NPI:1285064808
Name:CARLSON, LUCINDA
Entity type:Individual
Prefix:
First Name:LUCINDA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LUCINDA
Other - Middle Name:
Other - Last Name:CARLSON-MEDAVARAPU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA/CCC-SLP
Mailing Address - Street 1:415 WARNER AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4415
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1952 EAST 7000 SOUTH
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121
Practice Address - Country:US
Practice Address - Phone:855-440-9677
Practice Address - Fax:801-495-5303
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1325235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist