Provider Demographics
NPI:1134315047
Name:CARR, CLIFFORD WILLIAM (CCC-A)
Entity type:Individual
Prefix:MR
First Name:CLIFFORD
Middle Name:WILLIAM
Last Name:CARR
Suffix:
Gender:M
Credentials:CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1653 THORNAPPLE CIR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-5496
Mailing Address - Country:US
Mailing Address - Phone:219-477-4730
Mailing Address - Fax:219-462-6115
Practice Address - Street 1:1653 THORNAPPLE CIR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-5496
Practice Address - Country:US
Practice Address - Phone:219-477-4730
Practice Address - Fax:219-462-6115
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-25
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601000228231H00000X
IN23002893A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2822889Medicaid
MI2822889Medicaid