Provider Demographics
NPI:1932673316
Name:CARRASCO-CABA, MAXINE
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:CARRASCO-CABA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4475 HENRY HUDSON PKWY APT 5H
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10471-3865
Mailing Address - Country:US
Mailing Address - Phone:917-259-9407
Mailing Address - Fax:
Practice Address - Street 1:1 KENNEDY AVE UNIT 1113
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5772
Practice Address - Country:US
Practice Address - Phone:917-259-9407
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29957235Z00000X
390200000X
CT6143235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program