1417181314 NPI number — MRS. CASSIE ROSE CARBON-ELLINGTON M.S., CCC-SLP

Table of content: MRS. CASSIE ROSE CARBON-ELLINGTON M.S., CCC-SLP (NPI 1417181314)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417181314 NPI number — MRS. CASSIE ROSE CARBON-ELLINGTON M.S., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARBON-ELLINGTON
Provider First Name:
CASSIE
Provider Middle Name:
ROSE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.S., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BACZANSKI
Provider Other First Name:
CASSIE
Provider Other Middle Name:
ROSE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.S., CCC-SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1417181314
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
389 SUNLITE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOBART
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54155-9218
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-331-0418
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10150 W. NATIONAL AVENUE
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53227-5555
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-439-7012
Provider Business Practice Location Address Fax Number:
888-873-3992
Provider Enumeration Date:
05/06/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  2573-154 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1417181314 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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