Provider Demographics
NPI:1629291794
Name:POMILIO, CAROLE (MS)
Entity Type:Individual
Prefix:MRS
First Name:CAROLE
Middle Name:
Last Name:POMILIO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14618 S 34TH PL
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-7012
Mailing Address - Country:US
Mailing Address - Phone:480-704-0379
Mailing Address - Fax:
Practice Address - Street 1:8700 S KYRENE RD
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85284-2108
Practice Address - Country:US
Practice Address - Phone:480-783-4020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP5287235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ172523Medicaid