Provider Demographics
NPI:1174602239
Name:HENDRICKS, CARLA K (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:K
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4505 BALI CT NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-2801
Mailing Address - Country:US
Mailing Address - Phone:505-292-7104
Mailing Address - Fax:505-296-2183
Practice Address - Street 1:4505 BALI CT NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-2801
Practice Address - Country:US
Practice Address - Phone:505-292-7104
Practice Address - Fax:505-296-2183
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3606235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM63101025Medicaid