Provider Demographics
NPI:1578820262
Name:BACON, CASEY E (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CASEY
Middle Name:E
Last Name:BACON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 WESLEY ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1740
Mailing Address - Country:US
Mailing Address - Phone:423-282-1700
Mailing Address - Fax:
Practice Address - Street 1:302 WESLEY ST
Practice Address - Street 2:SUITE 8
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1740
Practice Address - Country:US
Practice Address - Phone:423-282-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-18
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4496235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist