Provider Demographics
NPI:1891128047
Name:WADE, CAROLYN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:WADE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2631 E DISCOVERY PKWY
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47408-9059
Mailing Address - Country:US
Mailing Address - Phone:812-856-0856
Mailing Address - Fax:866-981-1874
Practice Address - Street 1:2631 E DISCOVERY PKWY
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-856-0856
Practice Address - Fax:866-981-1874
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006047A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGMedicaid
IN000000830745OtherANTHEM PROVIDER NUMBER
INPENDINGMedicaid