Basic Information
| Provider Information | |||||||||
| NPI: | 1356435192 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PERRY | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | G. | ||||||||
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| Credential: | MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | # 2A300 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794306073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | SUITE 2A300 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794300002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067435678 | ||||||||
| FaxNumber: | 8067435670 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 01/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 16273 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 181350301 | 05 | TX | MEDICAID | 80397A | 01 | TX | HMO BLUE | OTHER | 80401A | 01 | TX | BC/BS | OTHER |