Provider Demographics
NPI:1770198434
Name:SPEED, CARLY (SLP)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:SPEED
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-4509
Mailing Address - Country:US
Mailing Address - Phone:513-746-5675
Mailing Address - Fax:
Practice Address - Street 1:18 N FORT THOMAS AVE STE 302
Practice Address - Street 2:
Practice Address - City:FORT THOMAS
Practice Address - State:KY
Practice Address - Zip Code:41075-1595
Practice Address - Country:US
Practice Address - Phone:859-441-0139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.20201467235Z00000X
KY284679235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0406425Medicaid