Healthcare Provider Details

I. General information

NPI: 1538675392
Provider Name (Legal Business Name): CAROL ANNE CARRUTH SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 PACIFIC PL
MOUNT VERNON WA
98273-5463
US

IV. Provider business mailing address

106 N RYAN ST
AUBURN AL
36830-5536
US

V. Phone/Fax

Practice location:
  • Phone: 360-416-7570
  • Fax:
Mailing address:
  • Phone: 205-243-6875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2000
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number76405
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLL60671043
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: