Provider Demographics
NPI:1336797786
Name:CARLSON, SYDNEY E (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SYDNEY
Middle Name:E
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 EATON AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1712
Mailing Address - Country:US
Mailing Address - Phone:231-675-9222
Mailing Address - Fax:
Practice Address - Street 1:421 BENSON AVE NE APT 2109
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-0026
Practice Address - Country:US
Practice Address - Phone:231-675-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-29
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101005803235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist