Provider Demographics
NPI:1811564826
Name:DECREDICO, CAROLYN MARIE (SLP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
Last Name:DECREDICO
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 1:523 BEL CREST TER
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23113-6491
Mailing Address - Country:US
Mailing Address - Phone:203-908-5862
Mailing Address - Fax:
Practice Address - Street 1:4110 E PARHAM RD STE 101
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23228-2776
Practice Address - Country:US
Practice Address - Phone:858-880-4672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000689235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist