=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356087787
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINA COMMUNICATION AND DYSPHAGIA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2022
-----------------------------------------------------
Last Update Date | 09/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 192 LONG FARM RD
-----------------------------------------------------
City | GARYSBURG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27831-9750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-578-8978
-----------------------------------------------------
Fax | 252-541-2062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 161
-----------------------------------------------------
City | SCOTLAND NECK
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27874-0161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-578-8978
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/SLP
-----------------------------------------------------
Name | CASSANDRA WADE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-578-8978
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------