Basic Information
Provider Information | |||||||||
NPI: | 1619316437 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SHOWALTER | ||||||||
FirstName: | CAROLYN | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.S.,CCC-SLP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HACKSLEY | ||||||||
OtherFirstName: | CAROLYN | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.S.,CCC-SLP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 913 VILLAGE SQ | ||||||||
Address2: |   | ||||||||
City: | GRETNA | ||||||||
State: | NE | ||||||||
PostalCode: | 680287853 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4029320747 | ||||||||
FaxNumber: | 4029915685 | ||||||||
Practice Location | |||||||||
Address1: | 913 VILLAGE SQ | ||||||||
Address2: |   | ||||||||
City: | GRETNA | ||||||||
State: | NE | ||||||||
PostalCode: | 680287853 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4029320747 | ||||||||
FaxNumber: | 4029915685 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/14/2013 | ||||||||
LastUpdateDate: | 07/10/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/10/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1795 | NE | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.