Healthcare Provider Details

I. General information

NPI: 1548744162
Provider Name (Legal Business Name): CASEY M CARROLL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CASEY CARROLL SLP

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 COUNTY ROAD B
SHAWANO WI
54166-7072
US

IV. Provider business mailing address

122 E COLLEGE AVE
APPLETON WI
54911-5794
US

V. Phone/Fax

Practice location:
  • Phone: 715-524-2161
  • Fax:
Mailing address:
  • Phone: 920-996-3264
  • Fax: 920-830-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: