Provider Demographics
NPI:1417181314
Name:CARBON-ELLINGTON, CASSIE ROSE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CASSIE
Middle Name:ROSE
Last Name:CARBON-ELLINGTON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MISS
Other - First Name:CASSIE
Other - Middle Name:ROSE
Other - Last Name:BACZANSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:389 SUNLITE DR
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:WI
Mailing Address - Zip Code:54155-9218
Mailing Address - Country:US
Mailing Address - Phone:414-331-0418
Mailing Address - Fax:
Practice Address - Street 1:10150 W. NATIONAL AVENUE
Practice Address - Street 2:SUITE 150
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53227-5555
Practice Address - Country:US
Practice Address - Phone:800-439-7012
Practice Address - Fax:888-873-3992
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2573-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1417181314Medicaid