Basic Information
| Provider Information | |||||||||
| NPI: | 1821765181 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SCALLAN | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11170 KEYSTONE TAVERN LN | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335784897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137167526 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18115 N US HIGHWAY 41 STE 800 | ||||||||
| Address2: | |||||||||
| City: | LUTZ | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335496475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138480341 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2021 | ||||||||
| LastUpdateDate: | 09/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | FL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SZ10318 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.