Provider Demographics
NPI:1497810600
Name:CARROLL, SUSAN (RD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:CARROLL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:372 MERIDIAN ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-5123
Mailing Address - Country:US
Mailing Address - Phone:617-398-7752
Mailing Address - Fax:857-264-5086
Practice Address - Street 1:360 W BOYLSTON ST RM 107
Practice Address - Street 2:
Practice Address - City:WEST BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01583-2370
Practice Address - Country:US
Practice Address - Phone:508-854-1380
Practice Address - Fax:508-854-1380
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA217133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALD0181OtherBCBS OF MA
MAAA51160OtherHARVARD PILGRIM
MALD0181OtherBCBS OF MA