Provider Demographics
NPI:1265035026
Name:TRAVERSA, CARLY MORGAN
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:MORGAN
Last Name:TRAVERSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1239 BELVEDERE AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-7940
Mailing Address - Country:US
Mailing Address - Phone:321-795-7829
Mailing Address - Fax:
Practice Address - Street 1:1239 BELVEDERE AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-7940
Practice Address - Country:US
Practice Address - Phone:321-795-7829
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2023-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ9579235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist