Provider Demographics
NPI:1609937218
Name:LOCKETT, CARROLL WILCOX (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CARROLL
Middle Name:WILCOX
Last Name:LOCKETT
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:2740 NW 17TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33311-4402
Mailing Address - Country:US
Mailing Address - Phone:954-793-0148
Mailing Address - Fax:954-301-0645
Practice Address - Street 1:2740 NW 17TH ST
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33311-4402
Practice Address - Country:US
Practice Address - Phone:954-793-0148
Practice Address - Fax:954-301-0645
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FLSA 7325235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist