Basic Information
| Provider Information | |||||||||
| NPI: | 1316370802 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MBWANA | ||||||||
| FirstName: | CARMEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | M.S., CCC/SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | COSENTINO | ||||||||
| OtherFirstName: | CARMEN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 197 THOMAS JOHNSON DR STE B | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217024314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016621997 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 197 THOMAS JOHNSON DR STE B | ||||||||
| Address2: | |||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217024314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2404158885 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2013 | ||||||||
| LastUpdateDate: | 05/07/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SL010954 | PA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.