Provider Demographics
NPI:1750751863
Name:CARLYLE, DARRELL
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:
Last Name:CARLYLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:551 CARLSON AVE UNIT 326
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2885
Mailing Address - Country:US
Mailing Address - Phone:925-623-6462
Mailing Address - Fax:
Practice Address - Street 1:551 CARLSON AVE UNIT 326
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2885
Practice Address - Country:US
Practice Address - Phone:925-623-6462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-01
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HISP-850235Z00000X
CASP-23606235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist