Provider Demographics
NPI:1679653505
Name:MCCOY, CAROLYN (PHD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:MCCOY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5129
Mailing Address - Country:US
Mailing Address - Phone:209-333-7316
Mailing Address - Fax:209-333-0370
Practice Address - Street 1:1001 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5129
Practice Address - Country:US
Practice Address - Phone:209-333-7316
Practice Address - Fax:209-333-0370
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU647237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU0006471Medicaid
CAZZZ15338ZMedicare ID - Type UnspecifiedAUDIOLOGY