Provider Demographics
NPI:1699928838
Name:CARR, CAROLYN JEAN (MS-CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:JEAN
Last Name:CARR
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 1:15441 MALLORY CT
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-3253
Mailing Address - Country:US
Mailing Address - Phone:805-523-1575
Mailing Address - Fax:480-287-8340
Practice Address - Street 1:15441 MALLORY CT
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-3253
Practice Address - Country:US
Practice Address - Phone:805-523-1575
Practice Address - Fax:480-287-8340
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-31
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP11314235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP0113140OtherBLUE SHIELD OF CALIFORNIA