Provider Demographics
NPI:1942610415
Name:DEBLECOURT, CARLA (MACCC/SLP)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:DEBLECOURT
Suffix:
Gender:F
Credentials:MACCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5639 PLEASANT MEADOW TRL
Mailing Address - Street 2:
Mailing Address - City:SCHOOLCRAFT
Mailing Address - State:MI
Mailing Address - Zip Code:49087-8107
Mailing Address - Country:US
Mailing Address - Phone:269-353-2747
Mailing Address - Fax:
Practice Address - Street 1:2575 N DRAKE RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-1358
Practice Address - Country:US
Practice Address - Phone:269-342-0206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101000464235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist