Provider Demographics
NPI:1881671394
Name:CAROLINA SPEECH SOURCE, LLC
Entity Type:Organization
Organization Name:CAROLINA SPEECH SOURCE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-322-7826
Mailing Address - Street 1:858 2ND ST NE STE 101
Mailing Address - Street 2:
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-3878
Mailing Address - Country:US
Mailing Address - Phone:828-322-7826
Mailing Address - Fax:
Practice Address - Street 1:858 2ND ST NE STE 101
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-3878
Practice Address - Country:US
Practice Address - Phone:828-322-7826
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-27
Last Update Date:2020-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7211073Medicaid