Healthcare Provider Details

I. General information

NPI: 1548389430
Provider Name (Legal Business Name): CARRIE L CILENTO M.A.CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

500 RAVENSTONE DR
CHESAPEAKE VA
23322-9118
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-9034
  • Fax: 757-668-9111
Mailing address:
  • Phone: 757-668-9034
  • Fax: 757-668-9111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202004056
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: