Basic Information
| Provider Information | |||||||||
| NPI: | 1578646865 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHARLOTTE SPEECH AND HEARING CENTER, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 741 KENILWORTH AVENUE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045238027 | ||||||||
| FaxNumber: | 7045238031 | ||||||||
| Practice Location | |||||||||
| Address1: | 741 KENILWORTH AVENUE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282042933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045238027 | ||||||||
| FaxNumber: | 7045238031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2006 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | TUCKER | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7045238027 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | CCC-SLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237600000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 235Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 7001530 | 05 | NC | MEDICAID | 7401042 | 05 | NC | MEDICAID |