Provider Demographics
NPI:1508401134
Name:CARROLL, MARY SHANNON (AUD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:SHANNON
Last Name:CARROLL
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1028 LAUREL TRL
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08836-2211
Mailing Address - Country:US
Mailing Address - Phone:908-872-0653
Mailing Address - Fax:
Practice Address - Street 1:140 BERGEN STREET
Practice Address - Street 2:E-1680
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103
Practice Address - Country:US
Practice Address - Phone:973-972-1017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YA00105600231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist