Healthcare Provider Details

I. General information

NPI: 1356087787
Provider Name (Legal Business Name): CAROLINA COMMUNICATION AND DYSPHAGIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 LONG FARM RD
GARYSBURG NC
27831-9750
US

IV. Provider business mailing address

PO BOX 161
SCOTLAND NECK NC
27874-0161
US

V. Phone/Fax

Practice location:
  • Phone: 252-578-8978
  • Fax: 252-541-2062
Mailing address:
  • Phone: 252-578-8978
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CASSANDRA WADE
Title or Position: OWNER/SLP
Credential:
Phone: 252-578-8978