Provider Demographics
NPI:1154682292
Name:MCDERMOTT, CARRIE R
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:R
Last Name:MCDERMOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PAM CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-1158
Mailing Address - Country:US
Mailing Address - Phone:631-275-6570
Mailing Address - Fax:
Practice Address - Street 1:1 PAM CT
Practice Address - Street 2:
Practice Address - City:SOUTH SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11720-1158
Practice Address - Country:US
Practice Address - Phone:631-275-6570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY514265111174400000X
NY363152911174400000X
NY563369112174400000X
NY516370112174400000X
NY516371112174400000X
NY563372112174400000X
NY1119438174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist