Provider Demographics
NPI:1568848471
Name:CARSON, MARY CLARE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARY CLARE
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1226 SAINT CHARLES AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-2533
Mailing Address - Country:US
Mailing Address - Phone:440-665-2757
Mailing Address - Fax:
Practice Address - Street 1:815 CROCKER RD STE 3
Practice Address - Street 2:
Practice Address - City:WESTLAKE
Practice Address - State:OH
Practice Address - Zip Code:44145-1072
Practice Address - Country:US
Practice Address - Phone:440-471-7190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-03
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.11692235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist