MEDICARE: CARLA HENDRICKS MS CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	8379	MA

General Provider Information

NPI Number	:	1184167801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLA HENDRICKS MS CCC-SLP

Provider Business Mailing Address
First Line	:	100 CUMMINGS CTR STE 135H
Second Line	:
City	:	BEVERLY
State	:	MA
Zip	:	01915-6127
Country	:	US
Telephone Number	:	978-927-0172
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 CUMMINGS CTR STE 135H
Second Line	:
City	:	BEVERLY
State	:	MA
Zip	:	01915-6127
Country	:	US
Telephone Number	:	978-927-0172
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2016
Last Update Date	:	11/29/2016

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