Provider Demographics
NPI:1023179744
Name:SLACK, CAROLYN (MS CGC)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:SLACK
Suffix:
Gender:F
Credentials:MS CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:PRC AND CREDENTIALING
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-273-0641
Mailing Address - Fax:401-273-2919
Practice Address - Street 1:101 PLAIN STREET, 6TH FLOOR
Practice Address - Street 2:MATERNAL FETAL MEDICINE
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4829
Practice Address - Country:US
Practice Address - Phone:401-274-1122
Practice Address - Fax:401-453-7622
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAGC067170300000X
RIGC00005170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS