Basic Information
| Provider Information | |||||||||
| NPI: | 1497243679 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENTEL | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | CCC/SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1721 S STEPHENSON AVE | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498013637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067765548 | ||||||||
| FaxNumber: | 9067765478 | ||||||||
| Practice Location | |||||||||
| Address1: | 1721 S STEPHENSON AVE | ||||||||
| Address2: | |||||||||
| City: | IRON MOUNTAIN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 498013637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9067765548 | ||||||||
| FaxNumber: | 9067765478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2018 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2605-154 | WI | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 7101003847 | MI | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.