Provider Demographics
NPI:1679635627
Name:FERTIL, CAVIN (MS CCC SLP)
Entity Type:Individual
Prefix:MR
First Name:CAVIN
Middle Name:
Last Name:FERTIL
Suffix:
Gender:M
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 1:12706 WOODROSE CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-1543
Mailing Address - Country:US
Mailing Address - Phone:704-549-0623
Mailing Address - Fax:
Practice Address - Street 1:12706 WOODROSE CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-1543
Practice Address - Country:US
Practice Address - Phone:704-549-0623
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6728235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412067Medicaid