Provider Demographics
NPI:1861834038
Name:MABUS, CAROLE JEAN (CAROLE MABUS)
Entity Type:Individual
Prefix:MS
First Name:CAROLE
Middle Name:JEAN
Last Name:MABUS
Suffix:
Gender:F
Credentials:CAROLE MABUS
Other - Prefix:
Other - First Name:CAROLE
Other - Middle Name:JEAN
Other - Last Name:SCHIRO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAROLE MABUS
Mailing Address - Street 1:10570 S FEDERAL HWY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5606
Mailing Address - Country:US
Mailing Address - Phone:772-380-9973
Mailing Address - Fax:
Practice Address - Street 1:10570 S FEDERAL HWY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5606
Practice Address - Country:US
Practice Address - Phone:772-380-9973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA3888235Z00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010802600Medicaid