Basic Information
| Provider Information | |||||||||
| NPI: | 1053337048 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WESTERN CAROLINA UNIVERSITY CONTROLLERS OFFICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WESTERN CAROLINA UNIVERSITY SPEECH AND HEARING CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | WESTERN CAROLINA UNIVERSITY SPEECH AND HEARING CENTER | ||||||||
| Address2: | 4121 LITTLE SAVANNAH RD. RM 132 | ||||||||
| City: | CULLOWHEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282277251 | ||||||||
| FaxNumber: | 8282277456 | ||||||||
| Practice Location | |||||||||
| Address1: | WESTERN CAROLINA UNIVERSITY SPEECH AND HEARING CENTER | ||||||||
| Address2: | 4121 LITTLE SAVANNAH RD. RM 132 | ||||||||
| City: | CULLOWHEE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28723 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282277251 | ||||||||
| FaxNumber: | 8282277456 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 12/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | RICE | ||||||||
| AuthorizedOfficialFirstName: | TRACIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SHC DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8282273378 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | AU.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1429 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 2693 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 721 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 231H00000X | 5214 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist |
ID Information
| ID | Type | State | Issuer | Description | 7001515 | 05 | NC | MEDICAID | 7210209 | 05 | NC | MEDICAID |