Provider Demographics
NPI:1134476542
Name:MUECKE, CAROLYN A (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:A
Last Name:MUECKE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:MISS
Other - First Name:CAROLYN
Other - Middle Name:A
Other - Last Name:TOLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:1515 LAKE HAVASU AVE N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86404
Mailing Address - Country:US
Mailing Address - Phone:928-854-5439
Mailing Address - Fax:928-854-5440
Practice Address - Street 1:2585 MIRACLE MILE ROAD
Practice Address - Street 2:UNIT #124
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442
Practice Address - Country:US
Practice Address - Phone:928-763-4030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZTSLP7867235Z00000X
AZSLP7867235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ738537Medicaid