Provider Demographics
NPI:1083084552
Name:CAROLAN, MARTIN
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:CAROLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 MILES RD
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01543-1423
Mailing Address - Country:US
Mailing Address - Phone:508-886-4746
Mailing Address - Fax:508-886-2274
Practice Address - Street 1:60 MILES RD
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:MA
Practice Address - Zip Code:01543-1423
Practice Address - Country:US
Practice Address - Phone:508-886-4746
Practice Address - Fax:508-886-2274
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-28
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11415702103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst