Basic Information
| Provider Information | |||||||||
| NPI: | 1114114048 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARTER | ||||||||
| FirstName: | TRICIA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CASSERO | ||||||||
| OtherFirstName: | TRICIA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1104 SCARLET OAK DRIVE | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527141863 | ||||||||
| FaxNumber: | 2523643226 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 MOYE BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278344300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527446104 | ||||||||
| FaxNumber: | 2527446148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 4244 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 1114114048 | 05 | NC | MEDICAID |