Provider Demographics
NPI:1205275021
Name:KING, CAROLYN ANN (MS, CCC/SLP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:KING
Suffix:
Gender:F
Credentials:MS, CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 BEVILLE RD
Mailing Address - Street 2:SUITE J
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-5797
Mailing Address - Country:US
Mailing Address - Phone:386-252-7837
Mailing Address - Fax:386-252-0021
Practice Address - Street 1:1104 BEVILLE RD
Practice Address - Street 2:SUITE J
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-5797
Practice Address - Country:US
Practice Address - Phone:386-252-7837
Practice Address - Fax:386-252-0021
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-15
Last Update Date:2013-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 6146235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist