Provider Demographics
NPI:1336620087
Name:CARROLL, ALYCIA LEANE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:ALYCIA
Middle Name:LEANE
Last Name:CARROLL
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 1:1106 IRONWOOD CC DR
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-5233
Mailing Address - Country:US
Mailing Address - Phone:309-706-3044
Mailing Address - Fax:
Practice Address - Street 1:1605 E OAKLAND AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-5617
Practice Address - Country:US
Practice Address - Phone:309-662-4302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146009500235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist