Healthcare Provider Details

I. General information

NPI: 1134369523
Provider Name (Legal Business Name): CARLA MCMANIMON M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MCKONKEY WAY
TITUSVILLE NJ
08560-1119
US

IV. Provider business mailing address

4 MCKONKEY WAY
TITUSVILLE NJ
08560-1119
US

V. Phone/Fax

Practice location:
  • Phone: 609-439-3599
  • Fax:
Mailing address:
  • Phone: 609-439-3599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number41YS00317200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: