Basic Information
Provider Information
NPI: 1033556055
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ALVARADO
FirstName: CARLOS
MiddleName: IVAN
NamePrefix:  
NameSuffix:  
Credential: CCC-SLP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3556 ASHFORD DUNWOODY RD NE APT E
Address2:  
City: ATLANTA
State: GA
PostalCode: 303195049
CountryCode: US
TelephoneNumber: 4047839974
FaxNumber:  
Practice Location
Address1: 3556 ASHFORD DUNWOODY RD NE APT E
Address2:  
City: ATLANTA
State: GA
PostalCode: 303195049
CountryCode: US
TelephoneNumber: 4047839974
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/31/2013
LastUpdateDate: 05/31/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000XSLP007768GAY Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

No ID Information.


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