Provider Demographics
NPI:1407142169
Name:CARLSON, MARY DOLORES (MED)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:DOLORES
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 MERRIMACK ST
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01843-1740
Mailing Address - Country:US
Mailing Address - Phone:978-552-4605
Mailing Address - Fax:978-552-4394
Practice Address - Street 1:360 MERRIMACK ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-1740
Practice Address - Country:US
Practice Address - Phone:978-552-4605
Practice Address - Fax:978-552-4394
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2829235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist