Provider Demographics
NPI:1700312345
Name:FINOCCHIO, CARLY
Entity Type:Individual
Prefix:MRS
First Name:CARLY
Middle Name:
Last Name:FINOCCHIO
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:CARLY
Other - Middle Name:
Other - Last Name:MELLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:80027A GENERAL PATTON ST
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13603-4054
Mailing Address - Country:US
Mailing Address - Phone:407-473-7767
Mailing Address - Fax:
Practice Address - Street 1:6800 GATEWAY BLVD E STE 4A
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79915-1006
Practice Address - Country:US
Practice Address - Phone:915-779-7827
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2021-09-08
Deactivation Date:2019-09-24
Deactivation Code:
Reactivation Date:2019-10-03
Provider Licenses
StateLicense IDTaxonomies
TX116237235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist