Provider Demographics
NPI:1306303490
Name:CAROLINA SPEECH ACADEMY, PLLC
Entity type:Organization
Organization Name:CAROLINA SPEECH ACADEMY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SPEECH LANGUAGE PATHOLOGIST/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:JANELLE
Authorized Official - Last Name:CARGILL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CCC-SLP
Authorized Official - Phone:856-264-3321
Mailing Address - Street 1:112 S CENTURION LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOLLY
Mailing Address - State:NC
Mailing Address - Zip Code:28120-8716
Mailing Address - Country:US
Mailing Address - Phone:856-264-3321
Mailing Address - Fax:704-601-5308
Practice Address - Street 1:112 S CENTURION LN
Practice Address - Street 2:
Practice Address - City:MOUNT HOLLY
Practice Address - State:NC
Practice Address - Zip Code:28120-8716
Practice Address - Country:US
Practice Address - Phone:856-264-3321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-25
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1306303490Medicaid
NJ1326462938Medicaid