Healthcare Provider Details

I. General information

NPI: 1063406726
Provider Name (Legal Business Name): CAROLYN BENNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 01/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 YALE AVE
MORTON PA
19070-1918
US

IV. Provider business mailing address

1820 CUMBERLAND AVE
CHARLOTTE NC
28203-6004
US

V. Phone/Fax

Practice location:
  • Phone: 704-408-1730
  • Fax:
Mailing address:
  • Phone: 704-408-1730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAT006098
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL009422
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: