Provider Demographics
NPI:1710509724
Name:ELASSAD, CAROL
Entity Type:Individual
Prefix:PROF
First Name:CAROL
Middle Name:
Last Name:ELASSAD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1292 CULPEPPER RD
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:MS
Mailing Address - Zip Code:39074-9114
Mailing Address - Country:US
Mailing Address - Phone:480-227-9276
Mailing Address - Fax:
Practice Address - Street 1:1292 CULPEPPER RD
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-9114
Practice Address - Country:US
Practice Address - Phone:480-227-9276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7052235Z00000X
TX112156235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX112156Medicaid
TN7052Medicaid