Provider Demographics
NPI:1316370802
Name:MBWANA, CARMEN (MS, CCC/SLP)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:MBWANA
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:CARMEN
Other - Middle Name:
Other - Last Name:COSENTINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:197 THOMAS JOHNSON DR STE B
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702-4314
Mailing Address - Country:US
Mailing Address - Phone:301-662-1997
Mailing Address - Fax:
Practice Address - Street 1:197 THOMAS JOHNSON DR STE B
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4314
Practice Address - Country:US
Practice Address - Phone:240-415-8885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010954235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist