Provider Demographics
NPI:1932471935
Name:FAHRENDORF, CARRIE (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:FAHRENDORF
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:11659 SYMMES CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-9341
Mailing Address - Country:US
Mailing Address - Phone:740-974-5400
Mailing Address - Fax:
Practice Address - Street 1:5945 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45213-1609
Practice Address - Country:US
Practice Address - Phone:513-363-4478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-07
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP9475235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist