Provider Demographics
NPI:1558343350
Name:CARLSON, MARY LOU (AUD)
Entity Type:Individual
Prefix:DR
First Name:MARY LOU
Middle Name:
Last Name:CARLSON
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 1:290 CENTRAL AVE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-8507
Mailing Address - Country:US
Mailing Address - Phone:516-239-6400
Mailing Address - Fax:516-239-6434
Practice Address - Street 1:290 CENTRAL AVE
Practice Address - Street 2:SUITE 116
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-8507
Practice Address - Country:US
Practice Address - Phone:516-239-6400
Practice Address - Fax:516-239-6434
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1026231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYM14461Medicare ID - Type Unspecified