Provider Demographics
NPI:1386246403
Name:DEEGAN, CARLY MARIE (MS, CCC/SLP)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:MARIE
Last Name:DEEGAN
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6245 STATE ROAD 54
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34653-6006
Mailing Address - Country:US
Mailing Address - Phone:727-376-1111
Mailing Address - Fax:727-376-1113
Practice Address - Street 1:6245 STATE ROAD 54
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34653-6006
Practice Address - Country:US
Practice Address - Phone:727-376-1111
Practice Address - Fax:727-376-1113
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-13
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA18493235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA18493OtherST OF FL, DEPT OF HEALTH, BRD OF SLP