Provider Demographics
NPI:1619179157
Name:BENNETT, CARLY VICTORIA (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:VICTORIA
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MRS
Other - First Name:CARLY
Other - Middle Name:VICTORIA
Other - Last Name:KIRSHENBAUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:4101 ROXBURY CT
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-9052
Mailing Address - Country:US
Mailing Address - Phone:954-854-8612
Mailing Address - Fax:
Practice Address - Street 1:4101 ROXBURY CT
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33436-9052
Practice Address - Country:US
Practice Address - Phone:954-854-8612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8845235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist