MEDICARE: MRS. CARLY VICTORIA BENNETT 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	SA 8845	FL

General Provider Information

NPI Number	:	1619179157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARLY VICTORIA BENNETT MS CCC-SLP

Provider Business Mailing Address
First Line	:	4101 ROXBURY CT
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33436-9052
Country	:	US
Telephone Number	:	954-854-8612
Fax Number	:

Provider Business Practice Location Address
First Line	:	4101 ROXBURY CT
Second Line	:
City	:	BOYNTON BEACH
State	:	FL
Zip	:	33436-9052
Country	:	US
Telephone Number	:	954-854-8612
Fax Number	:

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

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	07/08/2007

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