Provider Demographics
NPI:1689307050
Name:NELSON, CARLY JOANN (MS CF-SLP)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:JOANN
Last Name:NELSON
Suffix:
Gender:F
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 S VECINO DR
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-4119
Mailing Address - Country:US
Mailing Address - Phone:909-758-6417
Mailing Address - Fax:
Practice Address - Street 1:630 S INDIAN HILL BLVD STE 5
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-5461
Practice Address - Country:US
Practice Address - Phone:909-451-8521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-05
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist